When 8-year-old Gabriel Fernandez from Palmdale, Calif., died in May 2013 at the hands of his mother and her boyfriend — after years of abuse allegations called into the local child protection agency — it triggered a reckoning across Los Angeles County over why the system failed him so badly.
Nearly a year later, the Blue Ribbon Commission (BRC) on Child Protection, which was formed to conduct an independent investigation into the child protection failures that led to Gabriel’s untimely death, released its findings and recommendations for improvement.
Five years after the publication of those recommendations, the county has worked to make progress on preventing cases like Gabriel’s, including the creation of a new Office of Child Protection (OCP). But one issue — the provision of medical care for children in or at risk of entering foster care — has continued to vex the county’s reform efforts, particularly in the remote Antelope Valley region, where Gabriel and another young boy named Anthony Avalos died and which also has a disproportionately large population of foster youth.
Since 2004, medical care was supposed to be available at county-run hospitals through so-called “medical hubs,” funded mostly by the county’s Department of Health Services (DHS). The idea was that these hubs would be the central sites for forensic examinations of children in child welfare cases to determine if they had been been physically abused or neglected, and for ongoing care if they were removed into foster care.
For Gabriel, that exam never happened. Despite being the subject of eight allegations of abuse, he was never removed from his home.
“I think it’s fair to say, Gabriel Fernandez would still be alive today if he had been seen at a hub for a forensic medical examination,” said OCP Director Michael Nash at a recent meeting of the county’s Children’s Commission.
The recommendations handed down by the BRC five years ago today indicated that the hub system did not have sufficient resources to provide the necessary services to the some 34,000 kids with open child welfare cases. “There is inadequate access to medical and mental health services,” the report reads, noting that only one of seven hubs was available for services 24/7, and that the areas with the highest need had among the least access.
Under-Resourced and Misunderstood from the Start
There are seven hubs spread across the county, from the Antelope Valley’s High Desert hub to South Los Angeles. Six are operated by the county’s Department of Health Services (DHS), and the seventh is located at and operated by Children’s Hospital Los Angeles in East Hollywood.
The hub at the Los Angeles County + USC Medical Center (LAC+USC) is the most robust and busiest of the seven, due in part to the fact it is a magnet for philanthropic support. The other hubs rely solely on county dollars and Medi-Cal reimbursement.
Initially, the hubs were under-resourced and located in rundown spaces with challenges to find and maintain qualified staff to run them — especially at the far-flung High Desert hub, according to Dr. Astrid Heger, who developed the LAC + USC hub out of her Violence Intervention Program clinic.
“DHS wasn’t willing to fund at a higher level for staff to go out there, so it was hard to recruit,” Heger said of the Lancaster-based site 75 miles northeast of downtown L.A.
Heger said because of the staffing issues, the High Desert hub — where Gabriel would have been seen — went from being open five days a week, 8 a.m. to 5 p.m. to regularly having a hand-written sign taped to the door announcing the clinic was closed.
According the Dr. Shannon Thyne, DHS’s chief pediatrician, when staffing decisions were made for the hubs, there was little understanding of the child protection needs of each region.
“People haven’t always been deployed where they need to be deployed,” Thyne said at an April meeting of the Children’s Commission.
Heger argues that there had been a long-standing, strong protocol in place between the hubs and Los Angeles Department of Children and Family Services (DCFS). But with the High Desert center closed so frequently, it stopped becoming a go-to solution for social workers in the region.
“When Gabriel died, the clinic was closed half the time,” Heger said. “It’s kind of like the restaurant that’s closed half the time — you stop going.”
A Second Death Speeds Up Action
Though Gabriel’s death triggered the Blue Ribbon Commission and the 2014 recommendations, it took the death of second child to reign in county attention long enough to bring about serious changes at the High Desert hub, according to county officials. Anthony Avalos, another Antelope Valley child known to DCFS, was killed by his mother and her boyfriend in June of 2018.
Anthony, who was 10 when he died, lived in the same part the county as Gabriel did, and like Gabriel, was the subject of a series of abuse allegations over the course of several years before his death.
Two days before Anthony’s death, Heger visited the High Desert hub — where Anthony should have been examined — and found it closed.
“The staffing issue at High Desert was never resolved at all, and then we have another death,” Heger said. “All the recommendations were there, but there was no authority to hire.”
Following Anthony’s death, the county Board of Supervisors doubled down on its directive for improvements to be made in the hub system, especially at the High Desert hub.
An August 2018 report from the Office of Child Protection showed that the High Desert hub was staffed by just 1.8 full-time equivalent nurse practitioners, one part-time physician and one part-time nurse practitioner trained in forensic evaluations, despite it being the service area with the second highest rate of out-of-home foster care placement. There were no forensic pediatricians on staff, which the report attributed to the remote location and low pay for the highly-educated staff needed to properly identify and help mitigate child abuse.
Following the August report, DHS sent some staff from other hubs to the High Desert center temporarily to shore up services. One additional nurse was reassigned there permanently. On March 1 of this year, the county finally hired a board-certified child abuse pediatrician and Heger protégé, Dr. Phillip Hyden, to lead the High Desert hub.
“Under the leadership of Dr. Hyden we are bringing reform to that hub and making sure there’s always coverage with that expertise,” said Erick Matos, health deputy to Supervisor Katheryn Barger, who represents the Antelope Valley area.
Plans and Progress
A February 2019 report from the OCP found that the volume of forensic exams completed at High Desert has increased from 0-10 per month in the first quarter of 2018 to 20-30 per month for the same time in 2019 and that same-day acute forensic exams are available.
Matos with Supervisor Barger’s office said they’re looking at expanding High Desert’s hub service hours.
The coalition of county agencies — OCP, DCFS and DHS, along with the Department of Mental Health and the Health Agency — that developed the work plan to improve the hubs has submitted a budget request to the county for funds to hire additional positions. To help with recruiting, the county has added a location bonus for those who take positions at the High Desert hub.
Thyne of the county’s health agency has also been running trainings with the DCFS offices in the High Desert hub’s catchment areas to ensure better coordination between social workers and the hubs and has launched a pilot program to give social workers 24/7 on-call access to a forensically trained pediatrician who can help them determine if and when a child needs to be seen.
“Part of the project is to ensure that social workers and the hubs are clear on when a child should be referred to the hubs as part of a forensic evaluation, to make sure the social workers know the referral process,” Nash told The Chronicle of Social Change.
Moving in the Right Direction?
There remains some disagreement about what type of services should be offered at the hubs. Heger believes that initial medical evaluations, a key “core service,” which takes a baseline health measure for kids entering foster care, are important, but not key in saving children’s lives. She thinks instead, the hubs should focus on screening all youth who are suspected to have been subject to abuse or neglect, rather than devoting so much time and resource to kids who have already been removed from their homes.
“Neither Gabriel Fernandez or Anthony Avalos had [an initial medical evaluation] because they were never detained,” Heger said. “But if they had a screening exam they would still be alive.”
Heger takes issue with the idea that the hub improvement work plan is being developed by administrators, rather than providers who work with kids and know what the needs really are.
“I don’t think Mike Nash and his staff are medically trained enough to make decisions on what protocols should look like,” she said.
But Nash says it’s “absolutely untrue” that he and his staff are developing the protocols — they’re just the facilitators, he said, helping to remedy the BRC concern that child-serving agencies were too siloed.
“This is a wonderful example of agencies working together to improve services for kids coming into the system,” Nash said of the collaboration between DMH, DCFS, DPH, DHS and others who are working on the improvements. “We’ve got doctors around the table who have developed this plan.”
The Children’s Commission, which advises the Board of Supervisors on improving child and family serving programs in the county, heard updates on the hub progress at an April 1 meeting. They expressed concern that there still weren’t enough 24/7 service options and suggested that working to garner more philanthropic support could help augment funding limitations.
“It was a long time that we waited for the focus to shift to the hubs,” said Commissioner Wendy Garen, noting that there’s been frustration expressed over the five years elapsed since the BRC recommendations were issued. “But I have to say this is sort of worth waiting for because it feels like the beginning of transformational change.”
But Nash said there’s still much work to be done and a long way to go before the hubs are fully fixed in his eyes.
“We’re not going to rest until we ensure that the process for ensuring that our kids get these forensic medical examinations as quickly and as best as possible, because it truly is a matter of life and death,” he said.