The death of teenager Natalie Finn followed a series of errors and missed opportunities within Iowa’s child-protection system, according to the state Office of Ombudsman.
The office on Monday released a long-awaited, 160-page report detailing its investigation into the manner in which the Iowa Department of Human Services handled child-abuse reports pertaining to 16-year-old Natalie Finn of West Des Moines and her siblings. Finn was emaciated when emergency responders were called to her adoptive family’s home in October 2016, and she died a few hours later at a local hospital.
In its report, “A Tragedy of Errors: An Investigation of the Death of Natalie Finn,” the ombudsman’s office found that 14 child abuse reports had been made to DHS on behalf of the Finn children. The first three were made between 2005 and 2009. DHS records for those three initial reports were “scant or non-existent,” the ombudsman said, due to the agency’s policy for maintaining child-abuse records. The lack of any meaningful records related to those three reports prevented the ombudsman from reaching any conclusions on the appropriateness of the department’s response.
Ombudsman Kristie Hirschman’s report is critical of those record-retention policies, arguing they hinder the department’s ability to identify patterns of abuse.
In her written response to the report, DHS Director Kelly Garcia stated, “This was a tragic case … The Finn children should never have had to endure the treatment they received.”
“We will learn from this and improve the safety net DHS provides to Iowa’s children,” Garcia added. “Some of the work to improve the department’s response began immediately, but a large part of the department’s ongoing efforts will focus on finding better ways to support our team so they can better support the families we serve.”
Much of the ombudsman’s report focuses on DHS’s responses to the five child-abuse reports made between November 2015 to May 2016. Of those five reports, the first four were rejected by DHS intake staff, which meant they were not assigned to field staff for investigation.
The ombudsman concluded that three of those abuse reports should have been accepted for investigation. Included were two abuse reports, made six months apart, from school officials who described Natalie as “starving” and “very thin.” The intake staff at DHS did not document those descriptions, and both abuse reports were rejected for investigation.
The ombudsman’s report says Natalie’s fourth-grade teacher gave a “very credible” account of his interactions with Natalie, who told him of mistreatment at home, and of the 2009 report he made to DHS.
“The stories that (Natalie) told me, I mean, those will forever be ingrained in my head,” the teacher told the ombudsman’s office. “I mean, I remember every word of it.”
According to the ombudsman’s report, the teacher said that after making his report to DHS, he continued to receive information from Natalie about how she was mistreated at home. He said Natalie continued to exhibit signs of being extremely hungry, but because his report to DHS had been rejected for investigation, he developed a feeling of “distrust and animosity” toward the agency.
“My last resort was DHS,” the teacher told the ombudsman. “I thought they’d come in here on a white stallion and solve the problems.”
In reviewing the policies of other states, the ombudsman found that intake workers in Tennessee are required to read their written narrative back to anyone who makes a child-abuse report by telephone. Had such a policy been in effect at DHS’s child-abuse intake unit in 2015-2016, the report says, it may have allowed the people making the reports to DHS to point out significant errors and omissions, which could have resulted in those reports being accepted for investigation instead of being rejected.
The common thread in the child-abuse reports filed between November 2015 and May 2016 was that Natalie was not getting enough food at home. But no pattern was noticed by DHS until the fifth report, when a DHS worker took a step his or her colleagues did not and reviewed the four previous abuse reports about the Finn family. DHS intake workers are trained to check relevant histories in response to all reports of abuse.
The May 31, 2016, abuse report was the only one of the five that was accepted for investigation. The ombudsman’s office says there were a number of “serious missteps” made in the handling of that investigation: key witnesses were never identified or interviewed; the case was plagued by procedural irregularities; and the case was allowed to languish for extensive periods of time.
According to the ombudsman’s report, child-abuse call volumes and accepted intakes have increased significantly since Natalie’s death. This has resulted in a 36% increase to field workers’ average caseloads from 2016 to 2018.
While additional funding for field staff was approved in 2019, the ombudsman found that the increased call volume is straining DHS’s centralized child-abuse intake unit, where the number of intake workers has not increased since 2011.
“Although DHS received funding for the current fiscal year to hire additional field staff, I believe employees remain overworked, especially those in the intake unit,” Hirschman said in the report. “I am seriously concerned that the recent budget increase is insufficient, especially in light of the increasing numbers of abuse reports and investigations since Natalie’s death.”
Hirschman made 14 recommendations to DHS. Included are recommendations that the agency:
- Conduct a systemic review of the agency’s child abuse intake unit operations in light of the ombudsman’s findings.
- Modify its administrative rules to increase the retention period for child abuse intakes and assessments.
- Develop a policy for all intakes received by phone requiring intake workers to read their written narrative of the reporter’s statements back to the caller before the conclusion of the call.
- Provide training and written guidance on legal tools available to field workers when faced with resistance from parents.
- Provide training and resources for intake and field staff impacted by secondary trauma, decision fatigue and other job-related stress.
Hirschman is also asking the Iowa Legislature to re-evaluate its expectations for the Child Fatality Review Committee and other oversight bodies that are responsible for reviewing child deaths. The ombudsman found that the committee has never convened since it was established in 2000 following the death of 2-year-old Shelby Duis.
According to the report, DHS implemented some systemic changes during the course of the ombudsman’s investigation. In response to the report, DHS officials accepted 11 of the ombudsman’s 14 recommendations.
Natalie Finn’s adoptive mother, Nicole Finn, is serving three life sentences for her role in the teen’s death. Her adoptive father, Joseph Finn II, is serving a 30-year prison sentence.
In her report, Hirschman noted that “to our knowledge, our office is the only independent entity that initiated and completed an in-depth review of DHS’s actions involving the Finn family. The state medical examiner declined to convene an ad hoc Child Fatality Review Committee (CFRC) while the other oversight entities we identified had significant limitations in their resources and authority.
“By default, the ombudsman was the only entity capable of conducting an independent systemic review of DHS’s actions. This begs the question: What are the Legislature’s expectations of these other entities — particularly the CFRC — to review child fatalities? The ombudsman made the decision
to initiate this investigation because someone needed to.”