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We begin

The State of Connecticut is very forward thinking. Some years ago the Legislature established an Office of the Child Advocate (OCA) a watchdog agency charged with overseeing the well-being of children in the state, and a Child Fatality Review Panel (CFRP) empowered “(to) review the circumstance of the death of a child placed in out-of-home care or whose death was due to unexpected or unexplained causes.” (This and all further quotes are taken directly from the OCA report.) The purpose of such child fatality reviews was “to facilitate development of prevention strategies to address identified trends and patterns of risk and to improve coordination of services for children and families in the state.” In other words, the CFRP was instructed to approach each child death from the perspective of public health, and look for evidence of a systems failure. The primary goal of death reviews was not to assign blame in a punitive sense, but to determine what went wrong, in order to avert (or decrease the risk) of a recurrence. Further, the legislature directed that “upon request of two-thirds of the members of the panel . . . or at the Child Advocate’s discretion, the Child Advocate shall conduct an in-depth investigation and review and issue a report with recommendations on the death or critical incident of a child. The report shall be submitted to the Governor, the General Assembly… the commissioner of any state agency cited in the report … and the general public.”

In accordance with these provisions, OCA was directed “to prepare a report that would focus on Adam Lanza (hereinafter referred to as AL), and include a review of the circumstances that pre-dated his commission of mass murder at Sandy Hook Elementary School.” The review committee was composed of experts from the fields of psychiatry, law, social work, and education. Their charge was “to develop any recommendations for public health system improvement that emanated from the review. Authors of this report focused on AL’s developmental, educational, and mental health profile over time, the services he received from various community providers, and ultimately his condition prior to his actions on December 14, 2012. Authors looked for any warning signs, red flags, or other lessons that could be learned from a review of AL’s life.” The investigation commenced in January of 2013, and consumed nearly 2 years; their final report was published 11/21/2014. Available here.

Not only did the committee have the power to subpoena Adam Lanza’s medical and school records. The committee also had access to information gathered by law enforcement agencies, including police interviews, physical evidence collected from Mrs. Lanza’s residence, and Adam and his mother’s on-line communications. Finally, the committee invited various individuals to be interviewed for its report, but did not have the power to compel such participation (e.g. “OCA….extended an invitation to meet with Mr. Lanza, the shooter’s father, who in the late stages of the report’s development provided an extensive interview and private correspondence pertinent to this report”). Most of the time, all such information remains hidden from public view, protected by principles of medical, educational, or legal privacy. The mandate of the committee, however, was to disclose information that may be in the public interest. Thus, “the report… makes public major parts of the documents obtained through the subpoena authority outlined in OCA’s statute, for the purpose of informing the public and facilitating a means for follow-up of recommendations. Some information contained in this report may typically be considered confidential. OCA has deep respect for the laws and practice of confidentiality, but … OCA has the authority to disclose confidential information where the interest of a child or the public is affected.” The breadth and depth of information on which the report rests, and the interdisciplinary manner in which it is written, makes it most complete narrative of an incident of this kind available in the public record.

What does the record tell us? More next time.

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Shooting at Sandy Hook Elementary School – Report Of The Office Of The Child Advocate. We begin.The State of…

Posted by James Coplan, MD – Developmental Pediatrician / Autistic Spectrum Disorders on Wednesday, January 28, 2015

James Coplan, MD is an Internationally recognized clinician, author, and public speaker in the fields of early child development, early language development and autistic spectrum disorders. Stay connected, join Dr. Coplan on Facebook and Twitter.



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