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D
B
A
Present
in
the
room,
thank
you.
I
think
senator
mcgarvey
is
present
as
well
in
his
district,
but
I
don't
know
if
we
heard
him
say
that
okay.
A
All
right
before
we
get
well,
I
guess
I'll
ask
for
a
motion
to
approve
the
minutes
from
last
meeting
moved
by
representative
beckler
and
seconded
by
senator
nemes,
all
in
favor,
say
aye
aye,
all
opposed,
nay.
The
minutes
have
been
approved
before
we
get
started.
I
want
to
welcome
two
new
staff
members
that
we
have.
We
have
ryan
brown,
who
is
to
our
left
over
by
the
door,
and
we
have
taylor
johnston,
who
is
to
our
right
over
by
the
door.
Welcome
to
the
two
of
you.
A
They
are
both
from
graduates
from
the
university
of
kentucky
martin
school
of
public
policy
and
administration,
and
we
look
forward
to
working
with
the
two
of
you
without
further
ado
we're
going
to
get
into
the
the
meat
of
the
of
the
meeting
and
with
us
today
to
testify.
A
We
have
chris
hall
and
jeremy
skinner
and
we're
just
gonna
turn
the
turn
the
mic
over
to
you
guys
and
and
listen
and
we'll
have
questions
at
the
end.
Thank
you.
G
G
G
G
G
G
G
Furthermore,
our
analysis
showed
that
only
36
percent
of
the
recommendations
listed
a
particular
agency
or
entity
who
was
to
be
responsible
for
making
the
recommended
change
or
for
taking
a
particular
action,
and
that
was
given
in
the
recommendation.
G
The
committee
staff
second
finding
area
that
we
want
to
talk
with
you
today
about
relates
specifically
to
that
data
tool.
The
panel
uses
to
call
information
from
each
individual
case
file
now,
since
the
data
tool
is
the
primary
means
by
which
the
panel
collects
case-specific
information,
it's
important
that
that
tool
be
fully
evaluated
on
a
regular
basis
to
ensure
that
it's
still
meeting
the
panel's
needs.
G
G
Second,
the
panel
does
not
have
a
data
dictionary,
which
is
a
term
we
use
to
discuss,
to
describe
a
document
that
contains
standardized
definition
for
each
and
every
variable.
That's
being
collected.
Having
these
standardized
definitions
for
variables,
avoids
inconsistent
data
collecting
and
can
also
help
with
categorizing
case
information
in
a
systematic
fashion.
I
However,
neither
the
panel
nor
the
justice
cabinet
have
followed
the
procedures
outlined
in
section
4
of
the
mou,
which
states
that
the
panel
is
to
provide
its
budget
request
to
the
cabinet
in
the
fall
prior
to
the
budget
session,
which
the
cabinet
will
then
pass
on
to
the
office
of
the
state
budget.
Director
other
than
the
mou,
neither
party
has
developed
any
policies
or
guidelines
to
ensure
meaningful
communications
between
the
panel
and
the
cabinet,
as
it
relates
to
the
panel's
budget
and
expenditures.
I
I
Panel
staff
have
reported,
having
limited
knowledge
of
both
the
budget
process
and
of
the
panel's
available
funds
prior
to
2017.
The
panel
received
financial
updates
from
the
cabinet.
However,
it
does
not
appear
that
the
panel
has
received
financial
reports
or
updates
from
the
cabinet
in
recent
years,
while
the
panel's
expenditures
are
tracked
in
emars,
an
appropriation
allotment
was
not
created
for
the
panel
like
for
some
comparably
funded
programs,
which
are
also
in
the
justice
cabinet.
I
E
Thank
you,
mr
chairman,
gentlemen,
thank
you
for
your
presentation
this
afternoon.
How
are
the
this
data
reported
if
there
is
no
definition
set
forth
to
what
data
is
supposed
to
be
reported,
because
I
can
see
sometimes
under
reporting,
sometimes
maybe
over
reporting,
there
has
to
be
a
standard
set,
a
definition
to
go
by.
So
how
is
those
determinations
to
what
gets
reported?
What
doesn't,
how
has
that
been
handled?
Currently.
G
First,
let
me
clarify
some
terms:
the
data
tool
and
where
we're
where
we're
recommending
that
a
data
dictionary
needs
to
be
created,
is
the
panel
has
a
list
of
variables
that
it
will
look
at
when
it
pulls
the
case
file
and
they
have
to
realize
some
of
these
case
files
or
a
thousand
pages
or
more
include
videos,
pictures
just
an
amazing
array
of
stuff.
The
panel
doesn't
need
all
that
it
needs
certain
things,
so
it
would
say,
for
instance,
at
the
national
center
may
say
date
of
birth,
as
shown
on
the
birth
certificate.
G
G
G
I
cannot
answer
your
question
of
how
frequently,
let's
say
this
year:
they
recorded
interaction
with
dcbs
that
involved
these
things
next
year.
Somebody
said
you
know,
we
should
include
here
too,
that
we
do
this,
and
so
they
start,
including
that,
without
that
consistent
definition
agreed
upon
definition,
is
where
the
problem
arises
and
where
I
can't
really
give
you
a
full
answer.
It's
not
that
those
information
are
being
recorded.
It's
that
we
don't
know
how
consistently
those
data
are
being
called
from
that
that
file.
Does
that
make?
Does
it
make
sense.
E
E
To
me,
like
we
right
now
we're
very
inconsistent
in
what
may
or
may
not
be
being
reported,
and
that
can
create
problems
and
it's
a
very
simple
solution.
We
set
out
definitions,
so
everybody
knows
what
the
reporting
standard
is.
I'm
just
really
surprised.
We've
been
this
long
this
far
into
this,
and
we've
not
corrected
this
problem
already,
it's
it's
very
concerning
because
I
think
we
could
miss
a
lot
of
important
data.
That's
needed
to
to
help
for
us
to
make
determinations
on
how
we
go
forth
to
protect
our
our
children
in
kentucky.
A
Ask
that
question
of
the
panel
as
well
representative
when
they,
when
they
present,
maybe
they
can
answer
the
question.
Senator
carroll.
C
Thank
you,
mr
chairman,
and
appreciate
the
the
information
that
you
all
presented.
C
It's
been
a
while,
since
I've
I've
looked
at
this,
I
guess,
probably
since
last
year,
help
help
me
understand
in
my
of
all
the
things
you
told
you
all
told
us
the
thing
that
concerns
me,
the
most
is
the
fact
that
a
lot
of
of
the
findings,
the
follow-up
to
those
findings
is
not
doesn't
seem
to
be
always
specific
and
there's
no
accountability
that
anything
is
being
done
with
those
findings
and
if
that's
not
happening
with
every
case
that
they
review,
then
that
panel
really
doesn't
have
any
value.
C
I
mean
if
they,
if
they
review
it
and
they
find
things
that
need
to
be
changed,
but
yet
there's
no
consistent
accountability
that
those
things
are
changed.
Then
the
value
of
that
panel
is
gone.
It's
not
accomplishing
anything.
Can
you
all
elaborate
a
little
bit
more
in
that
area.
G
I
can
admit
it
was
not
necessarily
part
of
the
focus
of
this
year's
study
and
I
forget
which
year
it
was
that
that
was
looked
into
and
mentioned
and
brought
up
and
saying.
Well,
there
were
a
couple
points
I
would
make
statutorily.
G
They
have
no
teeth
in
in
terms
of
enforcing
these
things
and
then,
when
we,
if
I
remember
remember
correctly
in
those
reports
that
we
addressed
that
it
was
they
they're
so
busy.
Looking
at
these
cases
to
meet
that
statutory
mandate,
their
answer
was
we.
We
don't
always
have
time
to
check
up
to
see
if
those
recommendations
were
followed
on
because
of
of
staffing
with
the
staff
we
do
have
are
busy
helping
us
review.
This
year's
this
year's
cases.
C
And
that
that
too,
mr
chairman
may
be
something
that
the
panel
can
respond
to,
but
I
I
think
that's
something
we
probably
need
to
look
at,
because
I
I
guess
I
don't
understand
the
purpose
if,
if
there,
if
there
aren't,
if
there
isn't
an
accountability
at
some
level,
upon
those
recommendations,
maybe
not
necessarily
with
the
panel
but
within
the
particular
cabinet
or
agency
or
at
some
level,
you
know
what's
to
prevent
it
from
happening
again
if
we're
not
correcting
processes
or
actions
that
take
place
during
you
know
during
these
investigations,
that's
all
I
have,
mr
chairman.
A
Thank
you,
sir.
We
are
going
to
before
we
move
to
the
panel.
I
have
representative
fleming
on
the
line
with
a
question.
F
Good,
thank
you.
I
attended
the
child
welfare
welfare
advisory
committee
yesterday
and
the
dcbs
came
in
and
made
a
presentation
and
so
forth,
I'm
starting
to
get
a
clearer
picture
that
there's
a
systematic
issue
in
terms
of
what
senator
carroll
mentioned
in
terms
of
accountability
and
how
things
are
actually
set
up
and
based
on
what
I'm
seeing
in
terms
of
the
reports
on
the
on
the
current
cases,
as
well
as
the
past
due
cases.
F
Can
you
can
you
comment
on
on?
I
guess
the
the
actual
the
structure
of
those
two
entities
and
and
how
they
interrelate,
because
I
know
you
mentioned
things
in
in
your
presentation,
and
I
appreciate
that.
But
to
me
there's
a
there
is
a
systematic
structural
organizational
issue
in
terms
of
what
this
panel
function
and
what
they
do
versus
what
is
going
on
in
the
cbs
department.
G
Just
trying
to
think
how
to
organize
my,
I
would
say
a
couple
things:
one,
the
looking
at
the
dcbs
process
is
really
from
the
time
it
gets
a
call
that
an
allegation
of
abuse
goes
beyond
the
scope
of
our
charger.
Looking
at
this
panel,
there
is
indeed
interaction
with
dcbs,
which
is
what
objective
one
was
about
where
we
have
the
data
limitation
at
this
time
and
they're
still
working
on
getting
the
data,
and
so
I,
in
terms
of
speaking
about
data,
that
I
can
speak
to
of
how
that
process
works.
G
We
just
don't
have
those
data
yet
and
that's
the
and
that,
but
it
would
be
specifically
related
how
dcbs
evaluates
cases
of
fatalities
and
near
fatalities
and
makes
determinations
on
which
cases
get
forwarded
to
the
panel.
That
would
be
within
the
scope
of
our
charge
of
our
annual
charge
under
krs
260..
G
The
other
parts,
I
think
would
be
would
be
outside
our
our
scope.
I'm
hearing
you
and
I
understand
your
concerns,
but
I
the
only
the
only
aspect
I
think
that's
really
related
to
the
panel
for
what
you're
talking
about
is
where
what's
the
process
by
which
these
cases
are
being
selected
and
forwarded
to
the
panel
and.
F
Right,
do
you
think
the
pen,
I'm
sorry,
I
didn't
mean
to
walk
over
you
apologize
for
that.
Do
you
think
the
panel's
rolling
responsibility
should
be
expanded?
F
A
Representative
fleming,
I'm
going
to
let
our
staff
think
about
that
question,
because
I
think
it's
also
a
question
that
should
ask.
I
wonder
if
the
answer
is
the
statute's
okay
but
the
the
the
panel's
not
being
as
robust
as
what
they
were
designed
to
be
we'll
get
into
that.
I
want
you
to
think
about
that.
A
We
do
have
a
panel,
that's
going
to
testify.
One
person
is
here
so
make
room
for
if
you're
coming
up
steve,
I'm
going
to
turn
it
over
to
dr
curry
and
dr
curry.
If
I
would,
let
me
ask
you
to
drive
and
to
introduce
the
the
folks
that
you
have
with
you.
If
I
could
do
that
and
then
and
then
proceed
once
you've,
either
introduced
them
or
allowed
them
to
introduce
themselves.
H
Yes,
sir,
thank
you.
My
name
is
melissa,
curry,
I'm
a
child
abuse
pediatrician
with
the
university
of
louisville
school
of
medicine,
and
before
I
jump
in
I'm,
going
to
ask
my
colleagues
to
introduce
themselves
and
we'll
start
with
dr
salt.
J
B
K
H
Thank
you
very
much,
thank
you
chairman
and
to
the
committee
for
giving
us
the
opportunity
to
respond
to
the
work
of
the
committee
staff
in
their
oversight
of
our
panel.
We
appreciate
the
opportunity
I
do
have
a
powerpoint
that
I'm
going
to
spend
some
time
on,
but
I
want
to
address
just
a
few
issues
out
of
the
gate,
just
just
as
points
of
clarification.
H
H
We
do
continue
to
use
the
same
data
tool
in
essence,
although
we
have
added
some
data
fields
over
the
years,
so
that
we
can
compare
longitudinally
the
the
data
that
we've
gotten
so
that
we
can
see
what's
improving
and
what's
getting
worse-
and
I
I
will
mention
as
well
that
our
data
tool
has
about
240
data
fields,
which
is
pretty
extensive
data
to
collect
from
the
information
that
the
panel
is
provided
and
our
case,
analysts
are
the
ones
and,
and
the
panel
staff
are
the
ones
that
pull
that
data
and
input
it
into
the
data
tool
in
the
sharepoint
site.
H
I
wanted
to
point
out
that
the
panel
has
engaged
with
the
national
center
and
had
the
national
center
come
give
us
a
presentation.
It's
been,
I
think,
about
four
or
five
years
ago.
If
I
remember
correctly,
I'm
sorry,
I
don't
have
the
specific
year,
so
we
have
engaged
with
the
national
child
fatality,
review
resources
and
and
have
taken
their
resources
into
account,
as
we
have
created
the
structure
and
processes
of
our
panel.
H
So
I
did
want
to
clarify
that
our
reporting
has
not
actually
been
inconsistent.
We
do
have
definitions
for
each
of
the
data
fields.
With
that
said,
I
will
advance
through
the
slides,
as
was
already
mentioned,
the
panel
was
created
in
2012
by
executive
order
and
codified
and
statute
in
2014.
H
Our
purpose
is
conducting
comprehensive
reviews
of
child
fatalities
and
mere
fatalities
suspected
to
be
the
result
of
abuse
and
neglect.
The
panel
was
designed
to
reinforce
public
trust
through
transparency
and
oversight
of
the
panel's
work.
We
are
designed
to
be
an
independent
body.
We
are
administratively
housed
within
justice,
but
are
independent
thereof
and
to
further
insulate
the
panel
from
influence
from
the
administrative
branch.
There
is
a
memorandum
of
understanding
between
the
panel
and
justice
cabinet
defining
our
autonomous
role.
H
Membership
brings
together
multi-disciplinary
expertise,
representing
agencies
and
professions
who
interface
with
that.
First
family,
so
as
such,
we
are
a
panel
of
experts
as
opposed
to
a
citizen
review
process.
Members
are
recommended
by
respective
boards
or
governing
bodies,
and
several
of
the
nominations
are
submitted
by
the
are
submitted
to
the
attorney
attorney
general.
Who
then
makes
the
final
appointment?
H
We
are
unpaid
volunteers
and
we
meet
more
than
is
required
by
statute
statute
requires
us
to
meet
quarterly
in
2020
we
met
10
times
and
in
2021
we
have
been
meeting
monthly
in
order
to
effectively
get
through.
All
of
the
cases
that
have
been
provided
to
us
for
review
cases
are
referred,
as
has
been
mentioned
by
dcbs,
and
that
that
includes
the
cases
that
involve
fatalities
or
near
fatality
alleged
to
be
the
result
of
abuse
or
neglect.
H
So
we
don't
review
cases
of
children
who
die
unexpectedly,
for
whom
there
was
not
a
cps
report
or
an
allegation
of
abuse
or
neglect,
so
for
some
types
of
cases
that
we
review
we're
only
seeing
the
tip
of
the
iceberg,
dcbs
conducts
their
own
investigation
to
the
case
and
makes
their
own
substantiations
independent
of
the
panel.
Likewise,
the
panel
makes
its
findings
independent
of
the
findings
of
cps,
and
there
are
certainly
examples
of
cases
where
cps
has
chosen
to
unsubstantiate
a
case,
and
the
panel
has
chosen
to
make
a
finding
of
abuse
or
neglect.
H
Cases
are
also
referred
from:
the
department
of
public
health,
local
child
fatality
review
teams,
so
these
are
local
teams
with
first
responders,
generally
the
medical
examiner,
the
coroner,
maybe
representatives
from
ems,
dcbs,
etc,
who
are
reviewing
local
child
deaths
in
their
community
and
who
may
have
concerns
about
a
specific
case
that
may
not
have
ever
been
reported
to
dcbs.
So
we
have
a
second
pathway
for
cases
to
come
to
our
attention.
H
We
currently,
as
has
been
mentioned,
use
the
sharepoint
website
for
our
data
tool,
which
consists
of
as
I
mentioned,
about
242
data
points.
We
also
determine
the
type
of
case
or
the
category,
for
example,
drowning
or
physical
abuse
or
torture.
We
determine
and
code
family
characteristics,
as
well
as
other
qualifiers
and
a
final
determination.
So
the
final
determination
is
whether
abuse
or
neglect
was
found
and
what
type
of
abuse
was
found
in
the
panel's
review
of
the
case.
H
So
we
approach
these
cases
from
a
systemic
lens,
that's
important
to
understand
and
we
do
promote
accountability
while
avoiding
blame
of
individuals.
We
recognized
that
systemic
failures
are
never
the
result
of
intentional
or
wanton
behavior
on
the
part
of
any
individual
involved
in
the
investigation.
Indeed,
system
issues
are
not
the
responsibility
of
an
individual,
but
rather
failures
of
the
system.
H
We
recognize
that
difficult
decisions
are
made
by
frontline
staff
and
crisis
situations
and
we're
referring
not
just
to
dcbs
here,
but
also
law
enforcement
and
other
frontline
providers.
They
often
have
limited
information
at
the
time,
they're
making
their
decisions,
and
this
is
all
happening
in
the
context
of
agencies
that
are
beleaguered
with
staff
shortages
and
limited
resources.
H
So
it
has
been
mentioned
that
we
are
statutorily
required
to
publish
an
annual
report
each
year
consisting
of
our
case
reviews
our
findings
and
our
recommendations
based
on
what
the
panel
has
seen
most
of
in
a
given
year.
That
is
what
dictates
what
data
is
reported
in
the
annual
report.
We've
been
relatively
consistent
in
what
data
we
have
chosen
to
report
from
the
data
tool
and
it
has
included
those
findings
that
were
most
pertinent
to
the
to
the
largest
number
of
cases
and
we'll
discuss
a
few
of
our
recommendations
today.
H
H
H
So
this
is
the
fifth
consecutive
year
that
the
panel
has
addressed
the
need
for
family
drug
court
expansion
and,
at
this
time,
there's
only
one
jurisdiction
in
kentucky
that
has
implemented
family
drug
court,
and
that
has
been
with
private
findings.
I
will
interject
here
that
our
recommendations
are
data
supported.
H
We
would
like
to
have
more
data
driven
recommendations
in
order
to
do
that,
we
would
need
to
have
a
data
analyst,
which
is
something
that
has
been
requested,
but
has
not
yet
been
approved
for
the
panel
in
other
2020
recommendations
include
the
plan
of
safe
care
for
neonatal
abstinence
syndrome
and
neonatal
opiate
withdrawal
syndrome.
This
is
a
federally
mandated
plan
that
each
state
must
have
to
address
the
safety
and
well-being
of
infants
who
are
prenatally
exposed
to
drugs,
and
you
can
see
on
the
slide
this.
H
These
are
just
the
cases
that
we
reviewed
where
the
children
had
a
history
of
in
utero
drug
exposure,
so
the
in
utero
drug
exposure
was
not
in
and
of
itself
the
fatal
or
near
fatal
event.
It
simply
was
a
characteristic
of
the
case
in
the
child
cases
that
we
reviewed,
and
this
can
include
both
prescribed
and
illicit
drugs,
and
the
majority
of
children
were
exposed
to
more
than
one
subject.
H
J
H
While
there
are
strong
programs
available
in
some
areas
of
the
state
availability,
statewide
of
these
resources
is
sorely
lacking.
The
panel
recommended
that
the
department
of
behavioral
health,
developmental
and
intellectual
disabilities,
in
conjunction
with
the
department
for
public
health
and
dcbs,
examine
existing
practices
and
develop
strategies
to
address
deficiencies.
H
This
is
a
need
that
we
have
for
someone
to
own
this
process
the
plan
of
safe
care
plan.
In
order
for
it
to
be
implemented.
The
panel
also
recommended
that
the
child
welfare
oversight
and
advisory
committee
investigate
current
practices
related
to
the
plan
of
safe
care
and
provide
recommendations
to
support
implementing
statewide
practices.
This
was
our
recommendation.
Number
three
medication.
Assisted
therapy
is
an
evidence-based
approach
to
achieving
sobriety
for
opioid
addiction.
H
Mat
involvement
was
documented
in
just
over
10
percent
of
the
panel
cases
reviewed
in
2020,
even
though
those
families
benefited
from
that
treatment.
There
are
definitely
opportunities
for
improvement
on
the
part
of
mat
providers
when
providing
services
to
clients
with
young
children.
Providers
must
be
aware
of
the
elevated
risk
to
children
in
the
home,
and
this
risk
comes
from
unintentional
ingestion
of
the
medication
itself,
buprenorphine
or
suboxone
containing
pro
or
buprenorphine
containing
products.
H
There
are
also
co-sleeping
risks
when
the
caregiver,
who
is
using
medication-assisted
therapy
co-sleeps
with
the
child
and
monitoring
for
relapse,
so
providers
should
integrate
prevention
messaging
into
their
intervention
with
these
families
and
make
cps
reports
when
concerns
arise
to
the
level
of
suspected
abuse
or
neglect.
So
this
is
an
example
of
a
recommendation
that
specifically
says
that
it's
the
medication
assisted
therapy
providers
that
need
to
implement
the
recommendation,
but
the
panel
doesn't
have
the
authority
to
make
them
adopt.
The
recommendation.
H
Dcbs
and
mht
providers
need
to
collaborate
in
service
planning
and
provision,
so
regulatory
authorities
should
mandate
mat
providers
to
require
collaborative
services
to
pregnant
women,
mothers
of
infants
and
families
of
young
children
that
includes
prevention,
messaging
and
sharing
of
information
with
dcbs
and
compliance
should
be
tied
to
medicaid
funding
for
mhe
services.
H
In
other
words,
this
drug
testing
should
not
be
left
at
the
discretion
of
the
investigators
at
the
time
of
the
investigation,
but
should
rather
be
a
blanket
across
the
board
drug
testing
protocol
for
all
unexpected
child
deaths
of
note.
The
panel
has
developed
a
subcommittee
which
is
currently
developing
a
best
practice
approach
for
law
enforcement
when
investigating
child
death
or
near-death
scenes.
H
So
here
is
a
case
example
that
I'd
like
to
share
that.
The
panel
would
like
to
share
disregards
a
child
fatality
with
substance
abuse
issues
in
the
home.
This
was
a
traumatic
aesthyxia
or
suffocation
resulting
in
the
death
of
a
five-month-old
infant
father
placed
the
child
in
a
playpen
and
left
for
work
after
the
mother
arrived
home
for
the
evening,
mother
subsequently
found
the
child
on
response
unresponsive
in
the
playpen.
H
H
H
H
H
H
cps
had
ongoing
cases
opened
on
five
different
occasions.
The
family
was
before
the
court
for
the
fourth
time
after
the
fatality,
and
the
court
did
not
seem
to
engage
in
a
thorough
review
and
closed
the
previous
case
when
the
mother
was
seven
months.
Pregnant
and
receiving
medication
assisted
therapy.
H
Another
recommendation
includes
that
the
kentucky
department
for
behavioral
health,
developmental
and
intellectual
disabilities,
in
partnership
with
the
department
for
public
health,
should
develop
a
plan
to
expand
statewide
utilization
of
the
psychological
autopsy
in
child
suicides.
As
a
society,
we
tend
to
treat
mental
health
treatment,
especially
for
children
as
though
it
is
optional.
H
H
According
to
caseband
data,
suicide
is
one
of
the
ten
leading
causes
of
death
in
children
between
ages,
12
and
17,
and
a
primary
tool
to
help
us
understand
the
reasons
behind
a
suicide
and
to
then
further
our
knowledge
of
product
of
effective
prevention
strategies
is
the
psychological
autopsy.
This
is
a
process
that
involves
collecting
information
about
the
victim
through
structured
interviews
as
collaterals
by
trained
staff.
H
Kentucky
has
a
small
number
of
individuals
that
have
received
the
training
to
become
a
certified
psychological
autopsy
investigator,
and
this
is
an
encouraging
step,
but
an
infrastructure
to
begin
statewide
use
of
this
process
does
not
yet
exist.
Another
case
example
this
one
involving
the
suicide
of
the
10
year
old
child.
This
case
in
involves
the
suicide
or
I'm
sorry,
mother
reported
the
child
had
left
to
go
to
a
friend's
house
after
breakfast
and
upon
returning
home
they
were
cleaning.
H
The
house
mother
thought
the
child
was
cleaning
her
room
and
found
her
deceased
about
45
minutes
later
police
described
the
home
as
dirty
and
located
a
loaded
firearm
in
the
rear
bedroom
of
the
home
mother
described
the
child
as
happy
and
without
any
reported
issues.
However,
when
the
coroner
contacted
father,
he
reported
quote
unquote
concerns,
but
that
statement
provided
no
additional
explanation
in
the
coroner
records.
The
coroner
reporting
form
was
largely
incomplete
and
it
did
not
appear.
The
dcbs
was
notified
at
the
time
of
death,
as
is
required
by
law.
H
This
case
is
noteworthy
for
what
is
absent,
while
the
coroner
and
law
enforcement
made.
What
appears
to
be
an
accurate
determination
and
cause
of
death
being
suicide?
The
case
is
lacking
any
significant
information
regarding
the
psychosocial
background
on
this
family
and
the
panel
recommended
a
psychological
autopsy
be
conducted
in
this
case,
which
would
have
included
collecting
all
available
information
on
the
victim
and
conducting
structured
interviews
of
family
members,
relatives
and
friends.
H
From
a
partnership
perspective
during
the
last
year,
the
panel
has
partnered
with
k-span,
which
is
the
kentucky
safety
and
prevention
alignment
network
and
developed
the
child
home
safety
committee.
The
committee
focuses
on
research
and
implementing
evidence-based
strategies
to
prevent
in-home
injuries.
H
The
committee
received
grant
funding
from
the
cdc
to
prevent
these
types
of
injuries
and
to
date,
the
committee
has
purchased
501
medication,
lock
boxes,
250,
gun,
cable
locks
and
500
trigger
locks.
These
items
will
be
distributed
to
community
providers
and
will
be
accompanied
with
a
hard
copy
of
the
prevent
child
abuse,
kentucky's
home
safety
checklist
and
then
for
the
last
slide.
I
am
going
to
defer
to
my
colleague,
dr
salt,
who
will
talk
about
the
updates
that
we
are
making
to
the
data
tool.
J
Yeah,
so
thank
you
for
having
me
and
for
being
allowed
to
address
some
of
the
recommendations,
as
many
of
them
pertain
to
the
tool,
the
data
tool,
and
I
was
involved
with
the
process
to
try
to
address
some
of
the
recommendations.
I
think
primarily
because
of
my
role
as
a
researcher
collecting
longitudinal
data
using
the
software
platforms
that
we
are,
we
have
moved
to
and
then
also
I've
done,
develop
skills
and
with
psychometrics
of
scales
and
in
various
studies.
J
So
what
we
have
done
is
we
did
cross
check
the
current
tool
with
the
national
tool,
as
mentioned
by
dr
curry.
Our
current
tool
has
250
items
versus
the
national
tool,
which
has
2
500.
If
we
estimate
we
our
case
load
typically
in
a
month,
is
around
25.
If
we
have
one
minute
per
item
and
then
we
look
at
our
case
load,
we
would
need
at
least
five
analysts
which
we
have
two.
J
So
the
feasibility
of
using
the
national
tool
is
probably
a
huge
limitation
to
you
know
changing
tools,
also
from
a
researcher
standpoint
and
looking
at
collecting
longitudinal
data.
It
would
be
ill-advised
to
up
and
leave
your
current
tool
because
you
wouldn't
be
able
to
compare
year
to
year
equitably.
J
So
there
are
some
definite
limitations
to
foregoing
our
the
previously
used
tool
for
that
for
this
other
tool.
With
that
being
said,
we
have
gone
line
by
line
through
the
current
tool.
We
have
moved
it
to
redcap,
which
is
a
software
platform
which
allows
each
variable
to
have
its
own
name
and
it
creates
a
data
dictionary,
and
so
that
will
allow
for
data
analysis
to
be
more
easily
implemented
and
really
you
know
whatever
specific
variables
we
want
to
include
in
the
annual
report.
J
J
It
will
create
a
data
dictionary
which
will
define
each
variable
and
how
that
is
measured
and
the
responses
the
item
stem
and
then
the
responses,
but
we,
as
dr
curry
mentioned,
we
currently
have
operational
definitions
for
the
different
terms
that
are
used
in
the
in
the
analysis
by
our
and
that
is
now
being
housed
in
another
document
separate
from
the
actual
tool,
so
that
we
can
so
that
it's
clear
that
we
actually
had
these
two
sources
of
information
defining
our
different
variables.
J
As
far
as
the
I
think
that
those
were
the
primary,
we
also
have
received
input
from
the
department
of
public
health,
an
epidemiologist,
as
I
said,
we've
gone
line
by
line
through
through
the
current
instruments
and
have
taken
a
lot
out
a
lot
of
the
free
text,
which
was
also
a
concern
from
the
panel.
So
I
think
that
that
addresses
most
of
the
recommendations
made.
I
will.
I
will
mention
too,
that
there
was
question
as
to
the
utility
of
this
panel.
J
I
think
that
the
that
question
directly
contradicts
the
recommendations
when
you're
saying
use
the
national
tool
and
40
states
have
used
this
national
tool,
then
clearly,
all
the
other
40
states
you
value
in
this
panel.
This
panel
is
diagnostic
of
underlying
problems
that
we,
as
a
community,
face
to
try
to
that.
We
need
to
address,
as
dr
kerry
has
mentioned.
Through
our
recommendations,
we
have
made
efforts
to
move
forward
with
with
the
problems
that
that
have
the
problems
that
the
panel
finds.
J
So
I
think
that
that's
really
all
that
I
have
that.
I
can
I'm
for
I'm
happy
to
answer
any
other
questions,
as
it
relates
to
the
tool
or
the
panel
that
I
that
I
have
the
knowledge
about.
A
Okay,
I
have
a
question-
I
don't
know
if
it's
to
you
or
dr
salt
or
one
of
the
other
panelists,
let
me
lead
into
it,
and
that
is,
I
think,
we've
heard
that
about
10
of
what
the
national
organization
recommends
of
the
the
data
that
we
collect.
We
we
actually
do
collect
these
250
data
fields
and
they,
I
think
I
heard
they
recommend
2
500..
Are
there
some
of
the
data
fields
that
we're
not
collecting
important?
H
I'll
I'll
take
that
I
think
it's
important
to
understand
that
the
the
purpose
of
the
national
tool
is
different
from
the
purpose
for
our
tool.
The
national
tool
is
one
that
40
plus
states
report
on
in
order
for
data
to
be
gathered
about
different
states
for
national
reporting,
and
that
includes
things
like
the
family's
income,
for
example,
or
you
know
other
other
pieces
of
information
about
the
family
that
we
aren't
privy
to
as
a
panel.
H
I
think
if
we
were
to
try
to
dig
in
and
and
get
that
information,
we
would
actually
need
our
own
investigators,
because
that
is
often
information
that
neither
law
enforcement
nor
cps
collects
when
they're
doing
the
investigation.
So
while
we
do
code,
for
example,
the
data
field
of
whether
poverty
existed,
and
we
have
a
definition
that
we
follow
that
operationalizes
that
data
field,
we
do
not,
for
example,
collect
specific
family
income
information
and
that's
what
the
national
tool
collects.
H
A
A
I
would
think
that
the
reason
that
the
40
states
are
reporting
it
would
be
not
just
to
see
what
every
other
state
is
doing,
but
to
use
that
information
for
to
to
further
best
practices
in
their
own
in
their
own
states
and
with
their
and
just
taking
the
one
piece
of
information
that
you
identified.
You
guys
certainly
don't
have
that,
but
the
department
of
revenue
would
and
so
it
I
would
imagine
it
would
be
not
very
difficult
to
get
and
I'm
not
I'm
not
pushing
back.
You
know
in
any
in
any
accusatory
way.
A
I
understand
your
recommendation
or
your
response
says
that
there's
limited
authority-
and
it
very
well
may
be
that
the
statute
doesn't
give
you
that
authority
and
we
need
to.
We
need
to
give
that
to
you,
but
my
my
question
surrounds
also
in
your
response.
You
said
due
to
limitations
relating
to
staffing.
It
was
decided
that
the
national
tool
was
beyond
kentucky's
panel's
ability
at
the
time
that
may
be
so,
and
I
don't
know
if
anyone
up
here
thinks
that
you
need
to
do
all
the
2500.
A
Maybe
you
do,
but
250
10
percent
might
not
be
capturing.
The
information
that
would
allow
the
panel
to
do
its
job
more
effectively
and
when
you
couple
that
with
you,
only
have
two
case
analysts,
I
think
dr
salt
said
you'd
need
five.
A
If
you
were
to
to
do
the
national
recommendations
when
you
couple
that
information
with
the
the
fact
that
we
know
that
you're
not
using
no
and
no
blame
to
you
and
not
your
your
call,
I
would
suppose
you're
not
using
the
full
amount
of
money
that
we
have
been
appropriating
for
your
purposes.
Nor
are
you
allowed
to
even
make
the
request
to,
or
at
least
the
process
doesn't
call
for
you
to
make
a
direct
request
to
the
general
assembly.
It
has
to
go
through
the
cabinet.
A
I
think
maybe
there's
some
significant
room
for
improvement
there.
I
see
you
talked
about
independence.
I
see
a
lot
of
this
in
my
world
as
an
attorney.
The
department
of
public
advocacy
is
someone
that's
under
the
justice
cabinet,
but
we
understand
they
must
be
independent
and
so
the
dpa
their
commissioner
damon
comes
and
preston
comes
in
front
of
in
front
of
the
general
assembly
and
makes
their
particular
request.
A
It
might
be
if,
if
you
guys,
as
the
experts,
think
that
it
would
enable
you
to
do
your
job
more
effectively,
it
may
be
better
that
you
make
the
particular
request
of
the
general
assembly,
certainly
through
the
budget
of
the
justice
cabinet,
but
similar
to
what
the
dpa
does
and
that
we
can
actually
fund
and
make
sure
that
you
get
the
dollars
that
are
already
appropriated,
but
maybe
fund
extra
workers
case
workers,
investigators,
whatever
we
want
to
call
them.
So
you
can
do
the
extra
things
that
it
seems
like
to
me
anyway.
A
H
H
I
I
would
defer
to
I
believe
we
have
someone
from
the
justice
cabinet
and
the
budget
office
that
may
be
able
to
speak
to
that
more,
but
certainly
the
ability
to
hire
more
analysts
would
be
exceedingly
helpful
to
the
panel,
as
well
as
a
data
analyst
itself
I'll,
be
quiet
and
and
let
our
budgetary
person
speak
up
here.
I
just
want
to
interject.
J
B
J
B
Yeah
jason
hamilton
director
with
the
office
of
financial
services
here
at
the
justice
cabinet,
and
what
I've
heard
today
was
absolutely
there's
actually
some
truths.
There
is
not
a
separate
line
item
appropriation,
which
is
very
valuable
as
we
talk
about
funding
programs
or
departments
or
even
as
in
the
depths
of
allotments,
as
was
discussed
in
some
of
the
recommendations
as
well.
You
know
this
panel.
This
program
is
rolled
up
into
the
office
of
the
secretary
and
so
along
with
other
programs.
B
You
know
there
is
a
you
know:
they
compete
for
those
those
appropriations
that
are
that
are
granted
to.
You
know
this
authorized
from
the
general
assembly
to
this
cabinet,
and
so
as
as
we
have
been
since
I've
been
here
since
may
of
2020,
we
will
continue
to
be
supportive
and
collaborative
partner
with
the
panel
and
continue
to
listen
to
their
wishes
and
until
until
that
changes.
A
I
appreciate
that
I
would.
It
appears
that
the
base
funding
that
we've
appropriated
to
the
cabinet
is
not
all,
for
this
purpose
is
not
all
getting
there
and
I
know
there's
a
lot
of
competitive.
I
mean
I
used
to
be
until
this
past
year
in
charge
of
the
justice
cabinets
budget,
so
I
know
there's
a
lot
of
worthy
programs
that
are
underfunded.
No
doubt
about
that,
but
hey.
A
Yes,
certainly,
we've
got
two
in
front
of
you,
but
senator
unless
it's
directly
related
to
this,
but.
A
Real
quickly
senator,
but
if
it's,
if
it's
the
general
assembly's
priority
that
this
get
receiving
additional
funding,
then
maybe
the
cabinet
secretary
shouldn't
be
the
one
making
that
decision
that
we
should
make
a
line
item
of
direct
appropriation.
I'm
going
to
go
to
senator
thomas
because
I
think
he's
directly
really
what
I'm
saying
and
then
we'll
go
to
chairman
carroll,
senator
thomas.
D
William,
let
me
meet
myself.
Thank
you
chairman.
I
I
just
have
one
question
and
this-
and
this
is
to
all
the
presenters
to
today
a
bit
of
historical
background
back
in
2012,
our
statewide
press,
both
the
career
journal
and
the
lexington
herald
leader
were
bombarding
the
public
with
stories
of
the
of
numerous
child
fatality
deaths
across
the
state,
some
really
horrific
incidents
of
of
of
young
children
dying
and
as
a
result
of
those
numerous
stories.
D
The
first
governor,
steve
gover,
shares
steve
beshear
to
decide
to
form
this
this
child
fatality
panel
to
look
at
and
and
find
ways
to
stop
and
reduce
the
number
of
child
fatality
deaths.
Okay
and
since
I've
been
in
the
legislature
every
year
when
I
was
on
the
health
and
welfare
committee,
and-
and
I
think
one
year
we
had
an
interim
committee
just
on
this
panel,
now
we're
here
before
legislative
investigations
oversight.
You
know
I
I've
seen
annual
presentations
of
of
of
where
we
are.
D
D
Are
we
making
improvements
in
terms
of
reducing
number
of
child
fatality
deaths,
because
you
guys
have
presented
some
very
sobering
stories
this
afternoon?
I've
just
got
to
tell
you:
are
we
just
holding
our
own
or
are
we
getting
worse?
Please
answer
that
question
for
me.
H
I'll
I'll
attempt
to
give
an
answer-
and
then
it
looks
like
dr
salt-
has-
has
some
comments
as
well.
Perhaps
you
know
I
I
I
don't
think
we
know
where
we
would
be
in
kentucky.
If
this
panel
hadn't
been
in
existence,
you
know,
are
we
seeing
a
huge
drop
in
the
numbers?
No,
absolutely
not
we're
not
seeing
a
huge
drop
in
the
numbers
and
we're
seeing
worse
and
worse
cases.
H
What
we
don't
know
is
how
much
worse
might
that
have
been
if
we
didn't
have
the
panel
making
recommendations-
and
you
know
working
with
dcbs
about
you-
know,
areas
that
need
to
be
improved
and-
and
I
think
that
to
some
degree
that's
unknowable.
So
I
appreciate
I,
I
absolutely
appreciate
the
spirit
of
the
question
and
have
the
same
curiosity
about
you
know
what
what
impact
we're
having,
but
what
we
don't
know
is
is
where
our
numbers
will
be.
H
If
the
panel
wasn't
in
existence,
dr
salt
did
you
have
something
you
were
going
to
say.
J
J
C
Thank
you,
mr
chairman,
and
appreciate
all
the
information,
and
you
know
with
this
is
obviously
a
very
esteemed
panel
that
has
been
set
in
place
and
a
lot
of
credibility
and
and
not
to
maximize
the
recommendations
not
to
ensure
that
those
recommendations
are
followed
up
on
in
a
timely
manner.
C
I
think
is
a
travesty,
and
I'm
not.
I.
I
want
to
make
clear
that
none
of
my
comments
are
placing
any
blame
on
dcbs
or
law
enforcement
by
any
means.
C
I
think
we
can
all
agree
that
our
system
in
dcbs
is
inadequate,
simply
because
they
don't
have
the
staff,
and
that
is
that
is
an
issue,
an
entire
issue
into
itself,
and
we
we
are
failing
in
that
area,
talked
to
senator
higdon
yesterday,
who
had
met
with
some
social
workers
from
his
district
talking
about
the
shortages.
They
have
that's
something
that's
got
to
be
addressed
and
that
I
think
that
in
itself
is
a
significant
part
of
this
that
we
have
to
look
at.
C
C
Has
it
gotten
to
the
point
that
a
lot
of
times
it's
just
a
formality
to
put
these
out
and
you
don't
have
any
hopes
and
anything's
going
to
change,
because
if
that
is
the
case,
we
need
to
establish
a
direct
link
from
your
recommendations
to
someone
who
is
accountable
to
ensure
that
those
recommendations
at
a
very
minimum
are
researched
and
maybe
a
direct
link
to
the
legislature.
Also,
I
would
be
happy
to
carry
a
bill
that
required
drug
testing
on
fatalities
or
near
fatalities.
C
C
That
would
be
really
my
only
concern,
but
I
don't
think
setting
that
up
within
statute
would
be
all
that
difficult
just
having
to
understand
the
constitutional
implications
of
that
would
be
my
only
concern,
but
my
point
is:
if
there
are
direct
contacts
established
with
each
recommendation
and
then
some
accountability,
then
I
I
would
think
if
I
was
a
member
of
that
panel,
I
would
feel
a
lot
better
that
my
time
was
being
well
spent.
C
Obviously
you
you
give
me
an
amount
that
you
all
need
to
implement
your
programs,
like
the
legislature
intended
you
to
if
you
can
put
that
in
writing,
I'll
be
happy
to
try
to
get
added
to
the
budget
specifically
for
your
program,
and
I
know
there
are
many
members
sitting
in
here
right
now.
That
would
be
happy
to
do
that
also.
C
So,
with
that
being
said,
and
then
you
know,
should
we
put
some
requirements
that
each
year
for
your
recommendations,
that
that
those
recommendations
go
to
a
specific
cabinet,
a
specific
agency
and
give
them
six
months
to
to
finalize
whatever
efforts
they're
going
to
make
and
then
report
to
this
committee,
so
tell
me
what
what
we
can
do
to
to
make
your
process
more
effective.
C
H
Thank
you
senator.
I
appreciate
those
comments
and,
yes,
I
think
absolutely
anything
that
can
be
done
to
make
our
recommendations
more
to
improve
the
accountability
on
the
different
agencies.
H
No,
I
don't
think
the
panel
members
are
resigned
to
our
recommendations.
Being
you
know
relegated
to
the
back
page
of
the
report.
I
do
think
that
we
are
frustrated
many
of
us
that
more
hasn't
happened,
and
I
think
that
we
would
absolutely
appreciate
any
additional
support
on
the
part
of
the
legislature
to
help
you
know
hold
different
agencies
accountable.
H
I
will
say
when
you
ask
what
else
can
be
done
to
help
the
panel
work
better.
We
certainly
can
can
get
you
that
in
writing
as
far
as
a
dollar
amount,
but
we
do
have
two
appointed
legislative
committee.
Members
who
we
acknowledge
are
extremely
busy,
as
probably
most
of
the
members
of
the
panel
are,
but
we
have
not
had
participation
from
the
legislative
members
to
to
a
large
degree,
and
I
think
that
that
would
be
very
helpful
to
help.
H
The
panel
understand
what's
feasible
from
a
policy
standpoint
and
what
isn't
and
I
I
will
stop
talking
and
let
my
colleagues
I
don't
know
if
mr
shannon
has
anything
he'd
like
to
add.
K
Yeah
again
steve
shannon
with
mental
health
centers,
I
think
it's
a
great
question
co-chair
carol
what
happens
with
the
work
that
we
do?
Okay
and
I've
been
on
here,
five
or
six
years,
and
I
think
and
no
one's
getting
frustrated.
The
work
is
invaluable.
I
attend
a
lot
of
meetings.
My
wife
knows
when
I've
attended
this
meeting,
because
when
I
come
home
you
know-
and
a
lot
of
you
know
me
as
the
pension
guy.
You
know
pension's
a
diversion
from
this.
K
This
is
really
tough
work,
but
I
do
raise
the
question
and
I
think,
dr
curry,
you
know
we
need
to
get
teeth.
What
can
we
do
when
we
make
a
recommendation
who's
going
to
follow
that?
And
you
know
I
will
tell
you
and
I've
said
this
at
meetings-
the
front
line
dcbs
worker.
It
is
the
worst
job
in
state
government,
my
apologies
to
state
police
over
the
plant
and
corrections
these
folks
go
into
homes.
So
we
don't
want
to
be
critical.
It's
really
hard
though,
but
we
make
recommendations.
K
K
You
know
this
is
something
we
all
do
in
addition
to
our
job,
so
it's
hard
to
fit
that
time.
How
do
we
get
to
a
place
where
those
recommendations
is
it
this
committee?
Do
we
come
with
recommendations
to
this
committee
annually?
What
does
it
need
to
look
like?
What
can
we
do
so
I
you
know.
Other
members
have
told
me
that
we
make
recommendations.
We
think
it's
important.
What
happens
you
know
who
does
it
and
I'm
the
guy?
K
K
That's
enough
time
to
play
not
to
work.
I
don't
got
20
years.
This
is
one
of
those
things
we
need
to
figure
out.
The
stories
are
horrendous
and
we
need
to
get
systems
in
place
that
recommendations
move
forward.
I
sit
back
and
listen
to
the
likes
of
dr
curry,
okay,
dr
salt,
dr
curtly.
They
know
more
about
this
stuff
than
I
could
ever
imagine.
K
We
have
people
who
really
understand
what
needs
to
happen.
I
think
we
just
need
to
find
a
place
to
get
that
voice
heard
and
no
one
is
critical.
I
mean
dcbs.
Is
there
they're
participating?
We
don't
want
to
be
critical
frontline
workers,
but
where
can
we
go
to
whom?
Can
we
give
these
recommendations
so
they're
implemented?
That's
the
real
question.
C
C
Iron,
it
out
come
directly
to
a
legislator,
and
that
happens
all
the
time
and-
and
this
is
a
subject
that
I
don't
know
that
there's
anything
else
more
important-
that
we
do
in
frankfurt
and
especially
this
day
and
time
with
the
challenges
that
our
families
are
facing,
that
our
kids
are
facing
it.
It's
critical
that
that
we
that
these
systems
are
as
efficient
and
as
sound
as
they
can
be,
and
I
I've
been
there.
I've
worked
these
cases.
C
I've
made
mistakes
in
these
cases,
so
so,
knowing
that
there
is
a
body
that
that's
reviewing,
you
know
if
I
had
a
case,
it
was
a
fatality
and
I
failed
to
do
something
or
the
I
didn't
follow.
I
would
want
to
know
that
so
it's
invaluable
as
these
agencies
move
forward,
as
is
the
the
part
about
the
social
workers
and
and
taking.
K
C
And-
and
I
you
know,
I
think
we
do
have
to
work
on
that,
but
for
the
recommendations
themselves,
you
know
any
any
draft
legislation
that
you
all
could
come
up
with.
You
know.
Obviously
you
can
come
to
us.
We
can.
We
can
connect
you
all
with
bill
drafters
to
to
look
at
constitutional
things
and-
and
I,
for
one
and
and
anything
that
this
panel
does
based
on
my
background,
is
going
to
be
a
priority
on
my
legislative
agenda
and
senator
wise
with
his
background
representative
blanton,
several
others
here.
C
K
These
things-
and
we
haven't
been
that
and
I'll
own
as
the
guy
who
probably
should
have
been
pushing
that
agenda.
Okay,
but
we've
never
had
that
mechanism
truthfully
to
to
go
outside.
We
have
a
great
relation
with
the
justice
cabinet.
We
appreciate
that
relationship.
We
don't
want
to
disrupt
that.
We
work
very
closely
with
the
cabinet
of
health
and
family
service
dcps,
but
we've
never
had
that
you
know
is:
is
there
a
way
to
create
us
as
a
stand
alone,
and
I
think
at
one
point
people
talked
about
that,
but
we
just
never.
A
E
C
Yeah
yeah
and
it's
it's
and
I
think
we
I
think
they
would
agree
that
this
is
a
priority
knowing
secretary
harvey,
this
will
be
a
priority
for
him,
and
so
I
don't
think
it's
about
that
at
all.
But
it's
if,
if
a
system
like
this,
if
a
panel
of
this
magnitude
is
going
to
be
established
where
some
very
prominent
experts
are
giving
of
their
time,
we
as
a
legislature
have
got
to
make
sure
we're
giving
them
every
tool
to
succeed.
We.
Why
do
it
if
we're
not
going
to
do.
C
The
processes
are
in
place
and
I
think
it's
just
more
direct
contact.
I'm
I'm
ready
right
now
to
the
drug
testing
I'll,
follow
that
next
session.
I'd
be
more
than
happy.
K
I
think
it's
really
when
you
talked
about
authority,
I'm
not
sure
we
had
a
place
to
do
that
right.
So
this
is
a
great
opportunity
for
us.
You
know
raise
real
issues
that
we've
talked
about
a
lot,
so
I
think
that's
so
I
don't
know
if
there's
push,
because
we've
never
had
it
outside
of
our
meeting
this
conversation,
okay,.
C
K
A
E
Thank
you,
mr
chairman,
thank
you
to
the
presenters
first.
If
I
may
a
quick
comment,
then
I
have
a
question
for
for
dr
kerry.
E
Dr
kerry
was
explaining
one
of
the
cases
dealing
with
a
a
child
that
that
that
died
in
a
home
that
was
five
months
old
and
when
she
began
to
describe
the
way
that
that
home
was
the
the
way
that
child
was
living
in
that
residence.
I
heard
a
lot
of
gasps
from
members
of
the
committee
and
members
in
the
audience,
but
you
know
what
it's
a
shock
to
you
all,
but
to
our
dcbs
workers
to
our
law
enforcement
people.
E
E
I
once
went
into
a
home
with
social
workers
and
they
was
always
talking
about
taking
children
into
emergency
custody.
We
had
the
ability,
as
law
enforcement,
to
take
them
into
protective
custody
without
any
orders
and
I've
been
into
those
homes
and
I've
taken
children
at
my
discretion
into
protective
custody
because
of
the
conditions
that
dr
curry
described,
and
you
think
it's
bad,
you
have
no
idea
until
you
see
it
and
you
smell
it
and
you're
there
and
you
see
what
these
children
are
living
through.
E
It's
time
we
step
up
and
we
get
serious
about
children's
lives
and
and
and
everything
that
we
do
here,
but
so
I'm
I'm
supportive
of
giving
this
this
panel
every
tool.
It
needs
to
be
effective
to
do
the
job
that
that
the
people,
I
believe
that's
on
this
panel,
would
like
to
be
able
to
do,
and
so
you
have
my
full
support
of
that.
E
With
that
comment,
I
do
have
a
question,
dr
curry,
for
you
and
clarify
correct
me
if
I'm
wrong
here,
but
if
I
remember
in
my
notes
here
in
2020,
you
had
about
182
of
these
children
you're
anticipating
around
200
for
2021.
H
Yes,
I
don't
have
them
at
the
tip
of
my
fingers,
but
I
can
absolutely
get
those
to
you.
E
I
would
appreciate-
and
I
asked
that
question
because
during
everything
that's
went
on
in
our
world
over
the
last
18
months,
or
so.
We
we've
seen
an
uptick
in
in
crime.
We've
seen
an
uptick
in
domestic
violence.
E
I
want
to
see
the
numbers
go
back
years,
proceeding
into
this
to
see
if
we've
also
had
an
uptick
in
the
number
of
fatalities
or
near
fatalities
of
our
children,
with
everything
that's
been
going
on
over
the
past
18
months,
with
being
more
confined
at
home
with
parents
that
are
abusers
because
of
being
sent
home
from
work
or
school
shutdowns
and
those
type
things
have.
We
seen
an
uptick
also
in
in
this
realm
as
well.
So,
dr
perry,
if
you
could,
please
provide
those
to
the
committee,
I
would
appreciate
it.
Thank
you.
H
G
J
I
think
too,
that
the
concern
is
is
that
there
was
a
significant
decrease
in
reporting,
initially
after
after
covid
and
probably
because
only
16
of
cases
are
reported
by
people
that
are
not
professionally
linked.
So
you
know:
teachers,
healthcare
workers,
law
enforcement.
So
all
of
the
systems
to
report
child
abuse
were
disenabled
because
of
covid,
so
potentially
the
intensity
or
the
severity
of
the
cases
might
have
increased
because
people
weren't
responsive
to
to
the
to
the
situations
that
were
occurring.
J
So
I
think
that
there's
that
that
question
remains
we've
done
a
lot
to
look
at
like
comparing
suicide,
pediatric
suicide
before
and
after
covered
child
abuse.
Before
and
after
cobit
and
but
looking
at
healthcare
encounters.
So
it'll
be
interesting
to
see
the
evolution
of
this
specific
data.
K
A
So,
with
respect
to
the
numbers,
I
have
I'm
from
louisville
the
best
place
on
earth
to
live.
I'm
sorry
to
my
friends
that
don't
live
in
louisville,
but
you
should.
We
do
have
some
problems.
Obviously,
we've
got
a
lot
of
really
good
things
going
on.
One
of
the
problems
is
as
of
september,
23rd
we've
had
27
students
in
jcps,
who've
been
shot
and
killed.
Another
91
have
been
have
been
shot
and
survived.
A
Do
we
look
at
those
at
all?
Does
the
panel
look
into
that
those
over
100
kids
who've
been
shot,
27
of
whom
have
been
have
been
shot
and
killed?
Is
that
ever
something
we
look
at?
There
obviously
probably
is
some
abuse
and
neglect
in
those
situations
that
might
have
led
to
certain
situations.
I
don't
know,
but
do
we
ever
look
at
that.
H
No
sir,
those
cases
have
not
come
to
the
panel
because
there
has
not
been
a
report
made
to
dcbs.
In
those
cases
largely,
I
think
they
the
causes
of
those
cases,
get
attributed
to
external
factors
rather
than
internal
family
factors.
I
do
think
it
would
be
very
interesting
for
us
to
see
those
cases
and
dig
into
them,
but
as
as
the
panel
is
structured
currently
and
the
way
that
those
cases
come
to
us,
there
is
no
mechanism
for
us
to
review
those
cases.
Excellent
question,
though,.
C
Just
quickly,
dr
curry,
is
the
current
system
of
selection
on
what
you
all
review
is
that
the
best
way
to
do
it,
and
I
again
I'm
not
being
critical
of
dcbs
but
but
having
having
a
an
agency
choose
what's
reviewed
when
it's
often
their
work,
that's
being
reviewed?
Is
that
the
best
most
credible
way
to
do
that.
H
I
think
that's
a
great
question
overall,
I
think
yes,
I
think
it
works
well
because
they
send
us
all
of
the
alleged
fatality
near
fatality
cases,
regardless
of
whether
they
substantiate
the
finding.
H
So
to
my
knowledge,
we're
not
missing
cases.
Now
there
are
certain
types
of
cases
where
we're
only
seeing
a
small
fraction
of
the
overall
number
of
that
type
of
cases.
Sleep
related
deaths
would
be
an
example
of
that
you
know
one
could
make
the
argument
that
all
sleep-related
deaths
if
there
is
unsafe
sleep
involved,
should
be
an
allegation
of
neglect,
but
that's
not
how
dcbs
assesses
those
cases
so.
H
Consequently,
if
no
one
ever
calls
or
notifies
dcbs
or
makes
a
report
about
a
concern
for
neglect
or
abuse
in
those
sleep
related
deaths,
they
will
never
come
to
the
panel
for
review.
Now
there
is
another
review
panel
through
public
health
that
looks
at
those
deaths
and
they
will
at
times
hand
select
cases
from
their
reviews
and
send
them
to
us
through
public
health,
and
so
we
will
get
them
that
way.
H
H
A
F
It's
I
guess
it
seems
to
me
just
listen
to
the
discussion
and
so
forth,
but
really
the
general
assembly
sort
of
failed
this
panel,
because
I
think
there's
a
true
intent
to
get
it
going
and
so
forth,
but
we
can
give
you
all
the
tools
to
operate,
because
I
can
tell
that
there's
my
the
strong
mind
and
a
great
heart
behind
the
panelists
in
going
through
and
using
what
y'all
have
in
order
to
do
the
best
you
can,
but
it
seems
like
a
go
when
you
make
a
recommendation.
F
It
goes
in
the
bit
and
the
best,
so
I
just
want
to
first
of
all,
just
sort
of
so
support
with
other
comments
have
been
made
in
terms
of
we
will,
but
we're
going
to
be
committed.
At
least
I'm
going
to
be
committed
to
help
you
all
out
too
so
y'all
can
do
your
job
because
I
think
y'all
are
being
volunteered
and
going
through
this
process.
My
hats
off
to
you
going
through
the
stories
and
seeing
those
situations.
I
know
it's
difficult.
F
I
run
a
mental
health,
non-profit
faith,
sensitive
organization
and
I
see
a
lot
of
ramifications
of
what
y'all
go
through.
So
I
understand
wholeheartedly
is
going
on
and
if
there's
anything
we
can
do
I'll,
throw
it
out
to
to
senator
carroll
I'll
be
more
than
happy
to
carry
his
bill
on
the
house
side.
But
I
think
representative
blanton's
got
a
lot
stronger
law
enforcement
background
and
and
more
credibility
than
I
do
when
it
comes
to
that.
But
I
think
we
definitely
had
a
look
at
a
line
item
budget.
F
I
want
to
just
reiterate
some
of
the
things
that
that
has
been
said,
but
I
do
have
just
two
questions,
dr
curry.
Once
again
I
appreciate
you
and
your
panelists
for
all
what
y'all
do
and
on
a
side
note.
I
do
like
your
your
wall
back
there,
it's
like
nice
and
colorful,
so
it
keeps
you
nice
and
bright
and
shiny.
You
mentioned
about
psychological
autopsy.
Could
you
expand
on
that?
A
little
more
in
terms
of
what
goes.
H
So
a
psychological
autopsy
is
performed
by
someone
who,
or
at
least
is
led
by
someone
who
has
the
training
to
conduct
this
kind
of
investigation,
and
it
involves
talking
to
contacts
of
the
deceased
child
to
try
to
get
a
better
understanding
of.
Were
there
concerns
you
know.
Was
there
a
mental
health
need
that
wasn't
addressed
or
if
it
was
addressed?
Was
it
inadequately
addressed?
H
H
And
then
the
findings
of
the
autopsy
are
shared
with
community
organizations
that
do
prevention
work
so,
for
example,
the
the
school
system
and
we
have
suicide
prevention
programs
that
are
that
are
present
in
the
state
who
go
to
the
schools
and
give
presentations
if
they
better
understood
the
dynamics
of
what
causes
a
ten-year-old
to
kill
herself
that
that
may
then
be
built
into
the
presentations
to
the
school.
So
the
more
we
understand
about
why
the
kids
are
making
these
choices
and
where
we
are
missing
our
opportunities
to
prevent
it
from
happening.
H
The
better.
The
prevention
programs
will
be,
and
if
any
of
the
other
panelists
have
anything
to
add,
this
is
not
my
best
area
of
expertise.
I
will
say
I've
learned
about
the
psychological
autopsy
from
my
time
on
the
panel.
J
Need
the
better
it's
going
to
be
for
them
by
trade,
I'm
a
hospitalist,
and
so
the
amount
of
suicidal
ideations
and
suicidal
attempts.
We're
not
even
talking
about
completion
that
we
see
in
the
hospital,
especially
through
right
now,
has
been
staggering.
So
it's
definitely
kind
of
something
we
need
to
focus
on.
F
Well,
I
can
I
I'll
concur
with
that
that
statement.
Do
you
know
the
information
that
you
pass
along?
Do
you
know?
If
can
you
give
me
an
example
of
where
it
might
have
hit?
You
know
we've
had
some
pay
dirt,
where
it's
actually
rubber
hit
the
road
in
terms
of
them
or
in
our
organization,
actually
implementing
what
you've,
what
they've
come
up
with
with
that
report,.
H
I
don't
know
that
we
have
seen
a
completed
psychological
autopsy
at
the
panel.
I
think
that
we
have
made
those
recommendations
and
we've
talked
about
the
importance
of
it,
but
I
don't
think
that
we
have,
you
know,
determined
a
way
to
implement
those
or
to
to
have
them
implemented.
Mr
shannon,
you
look
like
you.
K
K
In
this
you
know,
I
spent
a
lot
of
time
in
the
health
world.
We
don't
have
a
lot
of
people
who've
been
trained
in
this.
I
think
this
is
a
new
piece
to
me
to
look
at
and
I
think
it's
an
opportunity
and
once
it
becomes
something
that
that's
viable
as
needed,
you
would
end
up
having
people
trained
on
how
to
move
forward
and
conduct
these
in
a
way
that
is
consistent
across
the
individuals
and
you
get
the
data
we
we
we
need
to
have.
K
I
think
it's
just
not
something
that
many
people
have
really
thought
about.
Maybe
that's
unfortunate,
but
I
think
that's
part
of
the
answer.
Representative
fleming
is
that
there's
just
I
don't
how
many
people
in
kentucky
are
really
certified
to
do
this
right.
I
mean
I've,
never
seen
that
number.
I
don't
know
if
there's
any
training,
I
know
you
know,
I
get
a
lot
of
training
stuff,
you
know,
but
I've
never
seen
anyone
doing
a
workshop
on
how
to
do
a
psychological
autopsy.
So
I
think
it
is
a
missed
opportunity.
J
F
And
that's
that's
going
through
that
autopsy
psychological
autopsy,
that's
raw,
powerful
information
that
I
from
my
side
now
I
I
would
I'm
drooling
to
get
that
information,
because
that
taking
a
holistic
approach
to
find
out
a
solution.
That's
the
way
to
go
so
whatever
you
do
to
help
to
do
that.
One
last
question,
mr
chairman,
should
be
a
real,
quick
one.
Dr
kerr,
you
mentioned
about
a
data
analyst
in
your
recommendation
and
so
forth.
Have
you
put
a
number
to
to
that.
H
B
F
K
B
Thank
you,
mr
chairman
question
on
suicide
among
teenagers
and
young
people.
I
doubt
that
the
young
person
understands
what
suicide
really
is.
B
Not
you
know
an
adult
in
general
knows
that
suicide
means
means
death
understands
what
death
is,
but
I
really
question
whether
or
not
a
young
person
does.
With
that
in
mind.
Have
there
ever
been
any
studies
that
show
what
kind
of
information
should
be
given
to
a
young
person
that
can
address
suicide?
B
It
just
seems-
and
I
I
would
suppose
that
with
all
the
esteemed
members
of
this
panel
that
that
an
answer
can
be
given,
but
it
just
seems
to
me
that
just
telling
young
people
that
suicide
is
bad,
you
know
it's
going
to
be
death.
I
I
can't
believe
that
they
understand
it.
So
has
anything
ever
been
done
nationwide
within
kentucky
to
to
kind
of
address
how
to
approach
a
child.
K
There
are
suicide
hotlines
there's
well,
that's
one
piece:
there's
groups
that
focus
on
teen
suicide
and
they
do
education.
They
go
to
schools,
they
do
prevention,
stuff.
Okay,
the
real
challenge
is
what
has
happened.
It
happened,
maybe
in
oldham
county
several
years
ago.
Chairman
name
is:
there
was
a
suicide.
There
was
two
or
three
that
followed
afterwards,
so
I
think
part
of
what
you
said
is
yeah.
They
really
get
it,
but
there's
groups
that
do
this
also
june
july
of
2022,
we
got
to
have
a
988
number
in
kentucky.
K
K
H
I
just
want
to
add:
there
is
data
about
what
most
effective
messages
are
and
what
ineffective
messages
are.
One
of
the
things
that
we
know,
for
example,
is
that
we
have
far
more
copycat
suicides
following
a
suicide.
If
the
media
reports
the
method
of
suicide,
we're
trying
to
you
know,
educate
the
media,
not
to
report
how
the
suicide
was
affected,
that
we
intentionally
left
that
out
of
the
case
presentation
today.
H
For
that
reason,
so
you
know
the
other
thing
is
peers
and
helping
peers
recognize
the
signs
of
suicide
and
empowering
peers
to
seek
help
for
children
who
are
in
pain,
and
you
know
I
I'm
gonna
go
out
on
a
limb
and
say
I
actually
think
the
children
do
understand
that
this
is
death,
and
I
think
that
we
sometimes
don't
wrap
our
heads
around
the
amount
of
pain
that
some
of
our
children
are
carrying
with
them,
whether
it
is
because
of
their
family
background
or
an
untreated
or
undiagnosed
mental
illness,
or
a
combination
of
the
two
history
of
abuse
or
neglect,
etc.
H
So,
yes,
it
is
the
prevention
programs
are
evidence
informed
and
that
research
is
ongoing.
E
Blanton.
Thank
you,
mr
chairman,
more
of
just
a
comment.
While
we've
had
the
questions
going
on,
I've
sat
here
and
and
did
some
math,
and
I'm
just
wondering
why
the
media,
while
we've
reported
on
all
a
lot
of
deaths
over
the
past
year,
our
child
fatality
rate
has
went
up
57
in
kentucky
over
the
previous
year
more
than
that
over
2018
57.
E
That
is
just
totally
unacceptable.
These
are
children
dying,
and
I
can't
figure
out
why
nobody's
reporting
that
we
had
18
increase
in
near
fatalities
over
that
same
time
period
and
overall,
with
near
fatalities
and
fatalities,
a
33
increase
over
2019
and
it's
it's
even
higher
than
that
percentage
over
2018.
E
So
it
just
befuddles
me
why
that
that
is
not
newsworthy
to
know
that
the
things
that
are
going
on
when,
when
all
this,
this
other
has
taken
the
main
stage
and
we're
doing
all
these
things.
What
about
our
children
their
lives
matter
too,
and
we've
had
a
57
increase
in
loss
of
children
because
of
these
circumstances
over
the
last
year.
Thank
you.
H
Thank
you
for
that
opportunity.
I
will.
I
just
want
to
clarify
that
we
do
not
review
all
child
fatalities.
We
only
review
those
where
there
is
an
allegation
of
abuse
or
neglect,
so
we
are
only
seeing
a
tiny
portion
of
the
overall
fatalities
that
we
see
in
children,
and
you
know
I.
I
think
that
there
is.
I
think
that
there
is
a
purpose
for
this
panel.
I
think
that
we
do
good
work.
H
I
think
that
we
have
done
good
work
and
have
seen
some
successes,
but
I
appreciate
the
committee's
commitment
to
being
helpful
to
us
and
to
you
know,
helping
us
develop
some
teeth
and
some
additional
funding
and
staffing
so
that
we
can
do
even
better
work
going.
B
G
We
talked
with
the
director
of
the
national
center
and
she
was
quite
complicated
that
the
whole
center
has
been
very
helpful
throughout.
This
entire
report
said
that
they
felt
they
could
the
their
system
could
take.
Any
information
kentucky
wanted
to
enter
now.
There's
over
2000
things,
there
doesn't
mean
you
have
to
enter
in
everything
if
they
wanted
to.
Our
point
was
that
there
are
a
lot
of
resources
at
that
center.
There
are
webinars
there.
They
will.
They
have
regional
people
working
that
will
come
to
kentucky
and
help
them
work
through
things.
G
They
have
publications
on
best
practices
for
making
recommendations,
best
practices
for
findings.
It
just
seemed
like
there
were
a
lot
of
resources
there
that,
as
the
panel
continues
to
move
forward
and
improving
his
data
collections,
how
to
make
recommendations
improving
their
data
tool
that
those
resources
would
be
available.
I
just
wanted
to
make
clear
to
members
that
we
weren't
saying
they
should
fully
adopt
the
national
center's
use
of
their
data
tool.
A
J
Yeah,
so
I
I
just
I
want
to
thank
you
again
for
allowing
us
to
present,
and
I
think
that
I
look
forward
to
ongoing
communication,
because
it
seems
like
we're
on
the
same
page
of
improving
the
issue
of
child
maltreatment
in
kentucky.
So
I
look
forward
to
ongoing
work.
A
Sounds
good
now,
I'm
going
to
have
to
have
a
we're
going
to
have
to
adopt
this
report,
but
before
I
do
one
of
the
presenters
mentioned
the
adult
drug
court
or
family
drug
court
in
jefferson
county,
and
it's
the
only
one
in
the
state.
We
need
to
expand
it.
It's
it
has
been
just
private
funded
and
I
want
to
call
out
some
some
some
folks,
just
in
particular
and
thank
them.
This
is
the
national
council
of
jewish
women
and
and
jane
emke.
A
C
A
Helping
us
get
the
adult
drug
court
in
jefferson
county.
Hopefully
we
can
expand
that
so
I'll.
Take
a
motion
to
adopt
the
report
motion
made
by
representative
blanton
seconded
by
senator
senator
carroll,
all
in
favor,
say
aye
all
opposed,
nay.
The
report
is
adopted
and
we
have
no
further
business.
So
we
are
adjourned.