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Critical Incident

Rapid Response
Team
Ahziya Osceola

Florida Department of Children and Families


April 27, 2015

Critical Incident Rapid Response Team


Ahziya Osceola
Southeast Region
Circuit 17
Broward County, Florida

Table of Contents
Executive Summary $$$$$$$$$$$$$$$$$$$$
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Introduction $$$$$$$$$$$$$$$$$$$$$$$
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Case Participants and Genogram $$$$$$$$$$$$$$$$$$$$$$$$$6
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Child Welfare Summary $$..$$$$$$$$$$$$$$$....
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System of Care Review. $$$$$$$$
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Practice Assessment $$$
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Organizational Assessment $$$$$$$$$$$$$$$$$...........................
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Service Array $$$$$$$$$$
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Critical Incident Rapid Response Team Report Ahziya Osceola

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Executive Summary
On March 20, 2015, the Florida Abuse Hotline received a report alleging that 3-year-old Ahziya
Osceola had been found deceased in his home the day prior, following an exhaustive search by
law enforcement, which began when he was reported as missing earlier the same day. Ahziyas
body was found inside two plastic bags, which had been placed inside a cardboard box, which
was then concealed under piles of clothing in the homes laundry area.
Subsequent to this discovery and additional investigation by law enforcement, Ahziyas
stepmother, Analiz Redezno-Osceola, was arrested and charged with Aggravated Manslaughter,
Child Neglect and Giving False Information to Law Enforcement. Ahziyas father, Nelson
Osceola, was also arrested and charged with Child Neglect. The remaini
remaining
ng children residing in
the household (one half-sibling and one step-sibling) were taken into custody
a

Because of these circumstances, Secretary Mike Carroll of the Department of Children and
Families deployed a Critical Incident Rapid Response Team ((CIRRT)
CIRRT) to the Southeast Region,
Circuit 17, in order to determine the nature and efficacy of the child welfare system involvement
with Ahziya and his family, and to assess potential systemic issues within the local system of
care. The review team consisted of representatives from DCFs Office of Child Welfare and
Childrens Legal Services, as well as the Department of Healths Office of Child Protection and
Special Technology, the Northeast Regions Office of Subst
Substance
ance Abuse and Mental Health, the
Seminole County Sheriffs Office and Community Based Care of Central Florida.

The CIRRT findings revealed an extremely complex family history of involvement with multiple
agencies within Broward Countys system of care, including:

Broward Sheriffs Office division of Child Protective Investigations (BSO CPI), which
conducts all child protective investigations in Broward County;
ChildNet, Inc. (ChildNet), which is the contracted Community Based Care lead agency
(CBC) which provides ongoing case management for Broward county;
Office of the Attorney General (OAG), which provides Childrens Legal Services for the
Department in Broward County;
Child Protection Team (CPT), which is administered by the Community Partnerships
Division of the Human Services Department of Broward County; and
Seminole Family Services, the social services agency administered by the Seminole
Tribe of Florida (the Tribe), of which Ahziya and several of his immediate and extended
relatives are recognized members.

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The comprehensive review of these agencies records, as well as face


face-to-face
face contacts with
involved staff, revealed a several years long pattern of substance misuse, generalized
neralized neglect
and physical injury to Ahziya,
ziya, which began while in the custody of his mother
mother,, Karen Cypress,
and ended while
le in the custody of Mr. Osceola and the joint physical care of Mrs. RedeznoRedezno
Osceola.
During the investigation of multiple reports that were received during that time, as well
w as the
resultant period of court-ordered
ordered supervision and services, there was a generalized failure to first
recognize then fully assess an emerging and worsening pattern of insufficiently explained
physical injuries to Ahziya. Given that the removal fr
from
om his mother (due to substance misuse)
misu
is
what resulted in Ahziyas placement in his fathers custody, the primary focus of the ongoing
court-ordered services was the mothers completion and/or progress on case plan goals aimed
toward reunification, rather than Ahziyas safety and well-being while in his fathers and
(eventually) stepmothers care.
This report presents the CIRRTs findings, including the child welfare history, the family
composition, a summary of the local chi
child welfare services provided
d and a comprehensive
analysis of the system of care. The findings are reported in the key categories of Practice
Assessment, Organizational Assessment and Service Array.

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Introduction
On March 20, 2015, the Florida Abuse Hotline (Hotline) received a report alleging that 3-year-old
Ahziya Osceola had been found deceased in his home the day prior, following an exhaustive
search by law enforcement, which began when he was reported as missi
missing
ng earlier the same day.
Ahziyas body was found inside two plastic bags, which had been placed inside a cardboard box,
which was then concealed under piles of clothing in the homes laundry area.
Subsequent to this discovery and additional investigation by law enforcement, Ahziyas
stepmother, Analiz Redezno-Osceola, was arrested and charged with Aggravated Manslaughter,
Child Neglect and Giving False Information to Law Enforcement. Ahziyas father, Nelson
Osceola, was also arrested and charged with Child Neglect. The remaining children in the
household (one half-sibling and one step-sibling) were taken into custody
a

Prior to his death, Ahziya and his immediate family (which includes a total of four half-siblings
and one step-sibling) had been the subject of multiple reports alleging abuse or neglect dating
back to April 2012. Ahziya was the subject of four (4) investigations received between August
2013 and December 2014, with the last of these being completed in early February 2015.
One of these reports, received in January 2014, resulted in the removal of Ahziya and his three
half-siblings from their mother, Karen Cypress, when it was determined they had been the
victims of verified Medical Neglect
he
Inadequate Supervision and
Substance Misuse. The children were adjudicated dependent, and each was subsequently
placed with his/her respective father. Ahziya was (at the time) the only child fathered by Nelson
Osceola, so he was the only child placed in Mr. Osceolas care. Ahziya and his half-siblings then
received approximately nine (9) months of court-ordered services and supervision - in their
respective placements - from ChildNet, Inc. (ChildNet). In addition, the family received services
and family advocacy from the Seminole Tribe of Florida (the Tribe), which continued even after
closure of the court-ordered services case, which was terminated by the court for Ahziya in
September 2014.

During the Critical Incident Rapid Response Teams (CIRRT) review, face-to-face interviews
were conducted with staff from Broward Sheriffs Office division of Child Protective Investigations
(BSO CPI), ChildNet, Office of the Attorney General (OAG) and the Child Protection Team
(CPT). In addition, several phone contacts were made with the Tribe, of which Ahziya and the
majority of his immediate family are recognized members. While Tribe representatives were
amenable to discussing general case management practices as well as ttheir
heir collaboration with
both BSO CPI and ChildNet staff, they ultimately declined to provide their written case records
specific to the Osceola family or to discuss this information verbally.

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Critical Incident Rapid Response Team Report Ahziya Osceola

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Case Participants

Name
Ahziya Osceola

Karen Cypress
Nelson Osceola
Analiz Redezno-Osceola
.

Age at
Time of
Incident
3 years
7 months
2 years
2 years
7 years
5 years
26 years
24 years
24 years
25 years
23 years
27 years

Relationship
Decedent
Half-Sibling to Ahziya
Half-Sibling to Ahziya
)
Half-Sibling to Ahziya (
)
Half-Sibling to Ahziya
Step-Sibling to Ahziya, Half-Sibling to
Mother to Ahziya,
Father to Ahziya and
Mother to
Stepmother to Ahziya
Father to
Father to twins
.
Father to

Genogram

(Child)

Nelson
Osceola

Karen
Cypress

Analiz RedeznoOsceola

Ahziya
(Decedent)

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Critical Incident Rapid Response Team Report Ahziya Osceola

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Child Welfare Summary


In August 2013, the first report was received involving then 2-year-old Ahziya and his three halfsiblings by their mother, Karen Cypress. The initial reporting sequence alleged that
approximately three days prior, Ms. Cypress had been observed in a highly intoxicated state
(e.g. falling out of a parked car door, vomiting) with the children in her care. Although law
enforcement had been notified of these circumstances at the time this allegedly occurred, Ms.
Cypress was reported to have left the scene prior to law enforcements arrival. In addition, the
report alleged a physical injury to Ahziyas face, for which Ms. Cypress had no reasonable
explanation.
The day following receipt of this initial report, an additional report was received by the Hotline,
which alleged that Ahziya would return from visits with Mr. Osceola having unexplained bruises
and smelling like marijuana. Despite this call containing additional allegations involving a
different Alleged Perpetrator (Mr. Osceola), the call was coded by the Hotline as only
containing supplemental information regarding the initial allegations rather than additional
allegations, which would require a separate response and additional assessment regarding those
allegations; neither did the BSO CPI initiate such a response on his/her own accord.

However, Ahziya was examined by a CPT physician during this investigation, who determined
that a bruise to Ahziyas left cheek was consistent with Ms. Cypresss explanation that he had
fallen and struck his face on the wooden frame of a bunk bed. As such, there were no findings
(by CPT) of an inflicted injury. Although Ms. Cypress denied any substance abuse problems and
there was no substantive evidence gathered to the contrary, CPT recommended that she
complete a substance abuse evaluation and follow through with any resultant recommendations.
CPT further recommended that Ahziya complete an evaluation to determine whether there was
the presence of any developmental disabilities.
Given that Karen Cypress is of Native American (Seminole Indian) descent (and by virtue of their
parentage, all four of her children)
children),, a Family Preservation Counselor with Seminole Family
Services served as a family advocate for the duration of the investigation. Prior to investigative
closure, the family had been referred and was voluntarily engaged in ongoing services with
Seminole Family Services; Ms. Cypress had begun substance abuse counseling and had
followed up with Ahziyas pediatrician, and he was already receiving speech therapy.
This August 2013 report was closed with Not Substantiated findings of Substance Misuse and
No Indicators of Physical Injury to Ahziya, and No indicators of Substance Misuse to the other
three children
)..
In January 2014, the second report was received involving Ahziya (then 2 -year-old) and his
three half-siblings, and this report resulted in all four children being taken into custody and
eventually being placed with their respective fathers.

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Critical Incident Rapid Response Team Report Ahziya Osceola

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This report was received when Ahziya was found unsupervised in the first floor lobby of a
hotel/motel where Ms. Cypress and her children had been staying in a fifth floor room. When law
enforcement arrived and determined Ahziyas identit
identity
y and Ms. Cypresss location, she was found
to be passed out from intoxication with at least one partial bottle of liquor in the room accessible
to the children. She was unaware Ahziya had exited the room and had been unattended for
approximately 30 minutes. She was, therefore, arrested on charges of Child Neglect. During the
arrest, Ms. Cypress incurred additional charges of Resisting Arrest and Battery on a Law
Enforcement Officer.
By the time this report was received and the BSO CPI responded to the location of this event, all
four children had already been released by law enforcement to the care of the
father,
., with whom Ms. Cypress and the children had been residing until one to two
weeks prior to her arrest.

Ahziya, who was the only child fathered by Mr. Osceola at the time (as
was not born until
August 2014), was eventually placed by the court in Mr. Osceolas care based on the
recommendation of Seminole Family Services. This was with the condition that Mr. Osceola
continued to reside with his own paternal grandmother. The reason for this stipulation, as
documented on the Home Study completed by Seminole Family Services, was that Mr.
Osceolas drug screen results were pending at the time of placement, as were outstanding
criminal charges the nature of which was not documented on the Home Study. The
were
placed with their father,
, and
was placed with his father,
(Note: Following his placement with
, there have been no additional reports
involving
as an Alleged Victim or
as an Alleged Perpetrator regarding any
child.)
The January 2014 investigation was closed with Verified findings of Medical Neglect and Not
Substantiated Findings of Failure to Thrive to then 13-month- old
. (who
had been medically evaluated following their removal due to obvious and severe growth
deficiencies), as well as Verified findings of Inade
Inadequate
quate Supervision and Substance Misuse to all
four children.
The dependency case against Mr. Osceola was later dismissed by the court, which considered
him to be a non-offending parent as to the circumstance that brought Ahziya into care. As such,
and aside from the same standard requirements being listed in the Case Plan for the Father (of
which there were three), there were no Case Plan tasks assigned to Mr. Osceola.

The children were later adjudicated dependent and continued to receive services from ChildNet
and Seminole Family Services in their respective placements.
The third report, received in April 2014, involved Ahziya only and alleged he had multiple bruises
on his body, including what appeared to be fingerprints and a bruise on the lower portion of each
side of his jaw line. He was additionally alleged to have sscratches
cratches on both sides of his neck, a
large bruise and bump on the right side of his forehead, a knot above one ear and bruises over
Florida Department of Children and Families
Critical Incident Rapid Response Team Report Ahziya Osceola

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(pinch
ch marks, bruises,
his left rib cage on his back. The report further alleged a series of injuries (pin
scratches, and a busted lip), which reportedly dated back to the end of March 2014. The
Alleged Perpetrator was unknown.
nknown.
Ahziya (who was by then 3-years
years-old) was initially seen at his daycare by the assigned BSO CPI
and Seminole Family Services. When asked a
about his injuries, he stated he had fallen in his
room (he provided this answer twice). However, staff at the daycare indicated when they had
asked him, he stated
ted his father had hit him. Staff members were additionally concerned over the
number of times Ahziya had arrived in the past several weeks with a number of assorted
bruises/marks, some of which were reasonably explained by Mr. Osceola and some of which
were not. In addition, Ahziya had recently missed several days of daycare and again was
observed with bruises upon his return.
When Mr. Osceola was interviewed, he indicated Ahziya had been with him at a family Easter
gathering over the weekend (this
this report was received on a Monday) and thats where/when he
had sustained the bruising on his face. He said all of the children at the gathering were running
wild and Ahziya ran into one of them, causing him to fall. Ahz
Ahziya
iya continued to play afterward so
he appeared
ared to be OK. Mr. Osceola was unaware of the bump on Ahziyas head but did state he
had fallen in his room as well as fallen off the toilet
toilet. Mr. Osceola expressly denied abusing
Ahziya, characterizing him as a child who falls all the time
time, does not pay attention to where he
is going, and as a result, runs into tables, countertops and other pieces of furniture which may
cause injuries. Mr. Osceola also offered that Ahziya simply bruised easily due to a low immune
system.
Ahziya was seen again for a medi
medical
cal evaluation at CPT, which resulted in positive findings for
physical abuse as the injuries on his face at the jaw line were consistent with fingertip marks
from being grabbed. The other injuries were deemed consistent with accidental injuries typical of
an active 3-year-old child.
May 2014 with Ahziya by ChildNet and Seminole Family Services
During a joint visit in mid-May
(while the April 2014 investigative was still open)
open),, Ahziya was noted to have a mark below one
eye that Mr. Osceola stated occurred whil
while
e Ahziya was playing around in the bathroom. Of note
is that this is a similar explanation provided by Mr. Osceola when he was previously questioned
about the origin of the suspicious lump on Ahziyas head.
During a joint visit in early June 2014 by the B
BSO
SO CPI and Seminole Family Services, there was
discussion regarding the Tribe seeking medical testing to determine if there was a metabolic
reason for Ahziya to bruise easily. At a later June 2014 home visit, ChildNet and Seminole
Family Services observed what appeared to be a rash on Ahziyas buttocks. Ms. Cypress was
the one to have taken note of and questioned this, so ChildNet suggested to Mr. Osceola that he
begin keeping a log to document each time Ahziya was injured and/or experienced any medical
problems.

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The April 2014 investigation was closed with Not Substantiated findings of Physical Injury to
Ahziya, without a specific individual being found responsible for these injuries. Based on Mr.
Osceolas explanation that some of the previous injuries observed by ChildNet, Seminole Family
Services and daycare staff were accidental in nature (falling in his room and falling off the toilet),
a Safety Plan was developed, which simply called for more direct supervision on Mr. Osceolas
behalf to avoid such falls from occurring
occurring.. This failed to address the CPT findings that at least
some of the injuries observed during his medical evaluation were intentionally inflicted and/or
indicative of abuse. Upon investigation closure, Ahziya continued under the previously initiated
services being jointly provided by ChildNet and the Tribe.
It was then determined during a monthly visit to Ahziya in July 2014 (conducted jointly by
ChildNet and Seminole Family Services) that Mr. Osceola had apparently been involved with
Analiz Redezno-Osceola for quite some time. Mr. Osceola expressly indicated he needed to
finish up the visit as Mrs. Redezno-Osceola (whom he referred to as his wife at the time) was at
the hospital about to give birth to their child,

Despite this information becoming known, there is no indication that ChildNet addressed the
addition of these new family members to the household, particularly as relates to Mrs. RedeznoOsceolas history with her own child and how this impacted or not her ability and willingness to
jointly provide safe and stable care for Ahziya. It is unclear from ChildNet notes whether this
history was obtained and examined at any point prior to the closure of Ahziyas ChildNet case,
which occurred two months later in September 2014.
During the CIRRT review, a background search regarding Mrs. Redezno-Osceola revealed that
several prior reports had been received on her child,
between April 2012 and April
2013, one of which resulted
being placed under in-home-court-ordered services with
ChildNet as well.
and Mrs. Redezno-Osceolas history is as follows:
f
).
,
s

.
nv
v

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Critical Incident Rapid Response Team Report Ahziya Osceola

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.
n,
n-

c
n

When
ChildNet case was terminated in April 2014,
remained in his
mothers care and custody. No additional reports were received involving
as an Alleged
Victim or Mrs. Redezno-Osceola as an Alleged Perpetrator (regarding any child) until the March
2015 report was received regarding Ahziyas death.
During home visits to Ahziya in July and August 2014, ChildNet indicated the intent to
recommend the case for closure at the next review hearing scheduled to occur in September
2014, and for the children to remain in the care of their respective fathers. This was in contrast
(as also documented) to Seminole Family Services desire to maintain the case as open to
provide Ms. Cypress additional time to fully complete her Case Plan tasks, with the goal
continuing to be reunification.

On September 9, 2014, the court terminated the ChildNet case involving Ahziya, per the motion
filed by Mr. Osceolas attorney. The court further maintained Ahziya in the full custody of Mr.
Osceola, and Ms. Cypress was granted unsupervised visitation each weekend.
The final report involving Ahziya (prior to his death) was received on December 7, 2014, and
again alleged Physical Injury by an unknown Alleged Perpetrator. The report (which contained
essentially the same information in two reporting sequences made by the same party on the
same date) specifically alleged that Ahziya had been seen at the hospital Emergency Room for
bruising on his face as well as complaints of painful buttocks when he sat down. The injuries
allegedly had occurred while Ahziya was in the care of Mr. Osceola and/or Mrs. RedeznoOsceola, and were noted by Ms. Cypress when she picked up Ahziya for an unsupervised visit.
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It should be noted this is the first investigation wherein Mrs. Redezno-Osceola was determined to
be residing with Ahziya and Mr. Osceola; they had been married in June 2014 and Ahziyas
youngest half-sibling,
had been born in August 2014.
During his exam at the ER, Ahziya was noted to hav
have
e a circular bruise with an overlying abrasion
on his cheek underneath his left eye. Ahziya was also noted to have some abrasions or tears in
the anal area, which the reporting party specifically stated (as per Ahziyas medical evaluation)
may be due to problems associated with severe constipation, but which had not yet been fully
confirmed. There were concerns/allegations that each time Ahziya sustained any injuries or
bruising while in the care of Mr. Osceola and/or Mrs. Redezno-Osceola, Mr. Osceola would state
Ahziya had simply fallen. However, when Ahziya was asked how he was injured, he said his
mommy hurt my butt (referring to Mrs. Redezno-Osceola). The reporting party, who had seen
Ahziya the day of the ER visit, described him as very happy, rambunctious and talkative. He
bounces off the walls.
The assigned BSO CPI initiated the investigation by calling to notify Seminole Family Services of
the new report. After also speaking with medical staff and confirming that Ahziyas injuries were
not severe, the BSO CPI and Seminole Family Services agreed that Mr. Osceolas paternal
grandmother should take Ahziya home from the hospital with her, and the BSO CPI would see
him the following day. (Note: This relative is the same individual with whom Mr. Osceola was
required to live when he was initially given custody of Ahziya following the January 2014 removal
from Ms. Cypresss care.)
Ahziyas diagnoses upon discharge from the ER were constipation, facial contusion, initial
encounter and abrasion.

When interviewed by the BSO CPI, both Mr. Osceola and Mrs. Redezno-Osceola denied having
abused or otherwise injured Ahziya intentionally. Mr. Osceola said he was at work when the
facial injury allegedly occurred, so his only knowledge of the events was secondhand from his
wife, who relayed to him that Ahziya was climbing on a wagon in his room, and despite being told
several times to get off the wagon, eventually fell and struck his face. Mrs. Redezno-Osceola
provided the same account of Ahziya having fa
fallen
llen in his playroom and injuring his face while
climbing on a wagon. She further advised that due to his low immune system she was very
careful with the foods she provided him to eat. Ahziya stated he had gotten a boo boo on his
face when he had fallen down. He denied he had been hurt by anyone, and stated his father,
mother and stepmother were all very nice to him. He also stated he had to go to the hospital for a
doctor to look at his boo boo.
In addition to the ER visit, Ahziya was seen for a thi
third
rd medical evaluation at CPT, two days
following commencement of the investigation. The written CPT report
report,, which was documented on
a Sexual Assault/Abuse Exam form, indicates positive findings for physical abuse with a specific
description of the facial injuries as follows:

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Ms. Cypress was interviewed by telephone the same day of investigative closure and indicated
that Mr. Osceola had not permitted her to see Ahziya since initiation of the investigation,
approximately two months prior. She stated that while she was previously completing her Case
Plan tasks and specifically when Ahziya was brought to visit her i
he
would often have some type of mark or bruise on his face.

Ms. Cypress further stated that while Ahziya was somewhat clumsy, she was concerned that
Mr. Osceola and Mrs. Redezno-Osceola were not providing proper supervision to prevent these
injuries from happening. She intended to speak with her attorney and seek to have her visitation
rights readdressed in court, given Mr. Osce
Osceolas
olas failure to comply with the previous order upon
termination of ChildNet services. She had continued to have weekend visitation with her other
three children
) with no difficulties.
Despite CPTs positive findings of abuse for Ahziyas facial injuries which were communicated
to the BSO CPI prior to investigative closure - this investigation was closed with No Findings of
Physical Injury and with no individual(s) being held responsible for the injuries. Mr. Osceolas
paternal grandmother continued to be actively involved in Ahziyas life and care, and sometimes
acted as a mediator between Ms. Cypress and Mr. Osceola regarding matters of visitation.
The BSO CPI, in conjunction with Seminole Family Services (which remained involved with the
family for the duration of the investigation), determined there was no need for a Safety Plan and
no need to initiate any repeat services from ChildNet.

System of Care Review


This review is designed to provide a comprehensive assessment of the child welfare systems
interactions with the Osceola family and to identify issues that may have influenced the systems
response and quality of decision-making.

Practice Assessment
PURPOSE: This practice assessment examines whether the child welfare professionals
assessments, actions and decision-making regarding the family were consistent with the
Departments policies and protocols.

FINDING A: There was insufficient assessment of Ahziyas safety while in his fathers care. This
occurred during individual investigations, over the period of time when yet more reports were
received at the Hotline with similar allegations of abuse, as well as during ongoing court-ordered
case management. This included occurrences of new injuries being observed, a pattern of repeat
injuries, and inconsistencies between parent/caregivers statements regarding the origin(s) of the
injuries.

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Of significant concern was the failu


failure to adequately assess the origin of and person responsible
for the multiple injuries that were medically determined to have been inflicted, and which were
mostly about the face, head and neck area of such a young child.
All but one of the reports alleging
ng physical injury to Ahziya occurred after he was placed in Mr.
Osceolas care, and Mr. Osceola always provided a similar explanation of simple
simpl falls or
accidents as the cause of these injuries. Although an active toddler can often incur typical
childhood injuries during everyday play, these are more often on the expose
exposed,
d, boney
prominences of a childs body, such as the shins, knees and elbows. Accidents
ccidents during play can
also result in the occasional abrasion,
asion, bump or bruise to the chin or forehead area, but such
injuries should be viewed with additional scrutiny - particularly when the same explanation is
provided for repeat injuries and when a medical evaluation confirms the injury is consistent with
being intentionally inflicted (e.g., the grab marks about Ahziyas chin and jaw line).
In addition, Ahziyas cognitive and developmental capacity, relative to his young age,
age make it
unlikely he was able to positively identify the cause and/or timeframes of the multiple injuries he
sustained over time. He would likely be unable to correctly differentiate the outcome of two
unrelated events that happened in close proximity to one another (e.g., being grabbed on the
face within the same relative period of time that he ran into another child and fell down,
down or being
struck by a caregiver within close proximity to him having fallen off a wagon in his room).
room His age
and size also made him physically vulnerable and still almost entirely dependent upon his
caregivers for his day-to-day
day care, and incapable of self
self-protection and/or self-reporting
reporting (i.e.
spontaneously telling a teacher, family member or other responsible adult who would take the
initiative to intervene in a protective manner
manner).
Furthermore, there was a pattern of over
over-reliance
reliance on parent/caregiver statements and a failure to
consistently utilize external (to the family) collateral sources to reconcile information and/or
evidence during investigations and ongoing case management. The parties often relied on the
statements of household members and/or the Tribe and did not seek out corroboration from
highly evident sources (e.g., failure to contact others who were at the Easter gathering to
corroborate the account of Ahziya having injured his he
head during a fall). Even in those
circumstances when prudent collateral contacts were conducted, this information appears not to
have been reconciled with information to the contrary
contrary, which was provided by the family. The
most significant of these circumstances is the April 2014 investigation wherein CPT made
positive findings of physical abuse (grab marks to Ahziyas face and jaw line)
line), yet this
investigation was closed as Not Substan
Substantiated
tiated with the perpetrator having not been identified.
Investigative documentation also does not indicate that additional family members (Mrs.
Redezno-Osceolas
Osceolas mother and two adult brothers) residing with the family during the last
investigation prior to
o Ahziyas death
death, were fully assessed in terms of their own histories
(abuse/neglect and criminal), the extent of their caretaking roles, their capacity to provide safe
and stable care, and whether or not their presence alone could pose a threat to Ahziyas
Ahziya physical
or emotional well-being.

Florida Department of Children and Families


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On the one occasion that a Safety Plan was developed in reference to Ahziya, due to the repeat
presence of multiple injuries to his head, face and neck area, the focus was simply that of
providing more direct supervision; it was never determined who had inflicted the grab marks (per
CPTs medical assessment) noted on Ahziyas chin and jaw line.
Lastly, a review of the ChildNet case chronological documentation did not reflect that any direct
services were provided by either ChildNet or the Tribe to Ahziya or Mr. Osceola, for the duration
of Ahziyas placement. While there was mention during home visits of parenting classes
(February 7 and March 19, 2014), a developmental evaluation by the Tribe for Ahziya (February
21, 2014) and a parenting coach (June 11, 2014), there was no subsequent documentation of
these services ever having been initiated and/or engaged. A June 11, 2014 note specifically
indicated that no services were being provided to the children. Some documentation by the BSO
CPI during its investigations did indicate that Ahziya was in daycare for a portion of his
placement.

FINDING B: Collection and sharing of information and evidence occurred in silo fashion and
was both inconsistent and insufficient among BSO, ChildNet, CPT, the OAG, the Tribe and the
Court.
Evident during the review was the absence of all parties coming together for any multidisciplinary staffings, even when the pattern of repeat injuries and/or successive reports began
and then continued to emerge. Ahziya and his three primary caretakers were the subjects of
seven investigations received in less than three years (April 2012 to December 2014), which also
resulted in two separate court-ordered periods of services and supervision - one for Mrs.
Redezno-Osceola with
and one for Ms. Cypress with Ahziya and his three oldest halfsiblings. Yet there was no indication these agencies ever recognized the need, either individually
or collectively, to gather as a group to ensure that all parties had the benefit of the collective
information each agency possessed.
In addition, there was a lack of attachments and document
documentation
ation with filed Judicial Review Social
Study reports about the case status, case plan progress and/or medical updates, which led to a
lack of detail available to the Court. This was significant particularly to additional investigations
regarding Ahziya after he was placed in Mr. Osceolas care. Of note was the absence of any
information regarding the April 2014 investigation (the first allegation of a physical injury to
Ahziya after being placed with Mr. Osceola) in the review report that was completed in late April
2014; neither was there any mention of this (per the court records) during the hearing itself.
Similarly, the CPT report regarding the positive findings for the grab marks on Ahziyas face was
neither filed with the court nor mentioned in the legal file. There was also no documentation to
support that the OAG was notified of this new investigation by either BSO CPI or ChildNet.
Lastly, while CPT findings were typically verbally communicated to the BSO CPI shortly after
CPT medical evaluations were conducted, the written reports were not provided in a timely
fashion and sometimes were received after investigative closure. In fact, the last CPT case

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regarding Ahziya prior to his death, from December 2014, was found to remain open with CPT at
the time this review occurred.
FINDING C: There was an over--emphasis
emphasis on completion and progress on Case Plan goals
related to Ahziyas mother, Karen Cypress, with no noted emphasis on ensuring
suring Ahziyas safety,
health and well-being
being while in the care of his father, Nelson Osceola.
While Ahziya was seen on an at--least monthly basis during ChildNets service provision,
provision the
details of these contacts reflect very little evaluative component(s) when it came to assessing
Ahziyas safety and well-being
being while in Mr. Osceolas care. Of the 11 documented visits to
Ahziya in Mr. Osceolas home (10
10 of which were made jointly by ChildNet and Seminole Family
th
Services; the 11 visit was made solely by Seminole Family Services), the details of all but one
visit were documented using the same documentation template, most of which was simply blank
and/or not applicable to Ahziyas circumstances.
Organizational Assessment
PURPOSE: This section examines the level of staffing, experience, caseload, training and
performance as potential factors in the m
management of this case.
FINDING A: There are diluted lines of responsibility, authority and actions that can be taken by
both BSO CPI and ChildNet staff
staff,, due to Tribal rights and authority per the Indian Child Welfare
Act of 1978 (ICWA). This
his includes matters relating to investigations, service provision, removal,
placement and reunification.
Of particular significance is information
information-sharing by the Tribe concerning its social services
involvement over the years with the family via Seminole Family Servi
Services.
ces. While both BSO CPI
and ChildNet reported very positive and collaborative relationships with the Tribe and Seminole
Family Services, this was based primarily on factors such as availability to conduct joint visits,
approval to access children
n and famil
families residing on the reservation, and generalized support
and advocacy provided to the families for the duration of investigations and court-ordered
court
service
provision.
When children of Native American/Seminole Indian descent are determined to be unsafe and
require removal from their parents/caretakers, the Tribe (via Seminole Family Services)
independently has the authority pursuant to ICWA to determine where the children will be placed.
A Home Study is completed by Seminole Family Services and presented to the court. BSO CPI
routinely completes criminal and abuse history checks on potential placements offered by the
Tribe (if the demographic information is available)
available), and is permitted to present any safety
concerns these checks reveal while at the shelter h
hearing. However, assigned Judges (who in
i
this familys case, was most often a Magistrate) are generally supportive of the placement
recommendations of the Tribe.

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FINDING B: Tribal
ribal representation, both in court proceedings as well as in the duration of
services being provided by Seminole Family Services, focused on family advocacy
advoca rather than
child advocacy.
Staff from the Office of the Attorney General indicated that while Guardians
uardians ad Litem (GAL) are
typically appointed to all removed children at tthe
he shelter hearing, they are also routinely and
immediately discharged by the court for any child of Native American/Indian Descent. This is
again pursuant to ICWA,, which stipulates the Tribal representative(s)
representative(s) role is to support the family
and advocate for
or the familys rights
rights.
Given that family advocacy can and often does differ from individual child advocacy,
advocacy in some
cases,, this can create circumstances where family and/or parental needs may take precedence
over individual
ndividual child needs for safety, permanency and well-being.
being. While its apparent that (at the
time) permanency for Ahziya was achieved with Mr. Osceola, it is not apparent that Ahziyas
needs for safety and well-being
being were ensured
sured as well (pursuant to the Findings in the Practice
Assessment section, above).
FINDING C: The number of investigative assignments for the involved BSO CPIs, and the level
of their child welfare experience,, were not deemed to be factors in the handling of prior child
protective investigations.
The four prior reports involving Ahziya were collectively investigated by a total of three BSO
CPIs; one CPI handled two of the investigations ((the January and December 2014 reports).
The following table provides information regarding length of employment, caseloads (based on
the number of investigations received per month) and any specific information regarding the
CPIs employment status during the months they w
were
re assigned their respective investigations.

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BSO CPI

Month Assigned
to Investigation

Experience
to Date of
Assignment
12 years

Comments

August 2013

# of
Investigations
Received
13

CPI A

CPI B

January 2014,
December 2014

13 and 6,
respectively

7 years
and 8 years,
respectively

Within recommended industry


standards for January 2014;
well below recommended
industry standards for
December 2014.

CPI C

April 2014

8 years

Well below recommended


industry standards. In addition
to handling these
investigations, CPI C was
serving as Acting CPI
Supervisor for Squad 5 during
this month, which
wh
had handled
all Institutional investigations,
i
as well as all investigations
involving children of Seminole
Indian descent since March
2014. Squad 5 employed a
total of five CPIs during this
time.

Within recommended industry


standards (12-15).
(12

Note: The number of investigations received does not include Supplemental Reports, Additional
Reports, Out-of-Town Inquiries or Out
Out-of-State Inquiries.
Service Array
PURPOSE: This section assesses the inventory of services within the Broward County child
welfare system of care where the Osceola familys case originated.
FINDING: Broward County has a comprehensive service array that includes Tribal-provided
Tribal
services, ass well as domestic violence, substance abuse and mental health providers who are
co-located and immediately available to both BSO and ChildNet staff
staff. Other than the matter
related to information-sharing
sharing and coming together as a collaborative team (which was
w discussed
as Finding B under the Practice Assessment section), the service array and availability of these
services were not determined to be a factor in the outcome for Ahziya.
The Tribe has an impressive service array for matters related to substan
substance
ce misuse and mental
health problems, and is also in the position to pay for private (outside of the Tribe) services when
a need is identified that cannot be met by the services available from the Tribe itself.

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The independent taxing district, the Childrens Services Council of Broward (the
the Council),
provides a substantial investment in family support services and works closely with BSO CPIs
and ChildNet leadership in identifying the need for these in
in-home family support services.
The Council funds high-quality,
quality, evidence
evidence-based
based programs that serve a significant number of
families identified by BSO CPIs in order to prevent them from crossing into the dependency
system.
Case-specific
specific progress for families served by the Councils programs is funneled back to BSO
CPIs, and those reports are then entered into the case record(s).
However, given that the Council provide
provides the majority of family support services as described, it
is also the source for determining the quality and value of such interventions. Because
B
ChildNet
does not develop its own resources as a part of its prevention efforts, the organization may be
disadvantaged at properly identifying the most effective resources fo
forr families such as Ahziyas.
Ahziyas
Another resource for investigators is a weekly roster of available referrals for families. This
roster contains information such as service description and location, target population and waitwait
list issues. The only noted concern by BSO CPI staff regarding
rding availability of a specific service
was for education and/or parenting classes geared toward parents of children with
developmental/behavioral disabilities and/or other special needs, as the
these
se services are often
limited due to space availability.
Lastly,
tly, given that Ahziya was a member of the Seminole Indian Tribe, ChildNet looked to the
Tribe to link the family to any necessary services as the Tribe and DCFs State of Nation Tribal
Agreement points to the Tribe providing these services.

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