Report: DHS discouraged complaints, then failed to investigate Sabrina Ray’s death

The September 2020 report from the Iowa Office of Ombudsman, "Misplaced Trust."

The Iowa Office of Ombudsman says the state agency tasked with protecting Iowa’s children wrongly rejected child-abuse reports in the months leading up to the starvation death of 16-year-old Sabrina Ray, and then failed to conduct an internal review of its own actions.

The newly published 146-page report also takes DHS to task for having “actively discouraged” one individual from continuing to relay her concerns about suspected child abuse in the home where Sabrina Ray lived.

In a preface to the report on her office’s investigation into the Perry girl’s death, Iowa Ombudsman Kristie Hirschman cites “the unspeakable abuse and unimaginable pain” ensured by Sabrina prior to her death in 2017 and says she finds it “unfathomable” that in the wake of the Perry teenager’s death, the Iowa Department of Human Services conducted no internal review of its actions and decisions in the case.

Titled “Misplaced Trust: An Investigation of the Death of Sabrina Ray,” the report notes that between 2010 and 2015, DHS fielded 11 child abuse reports against Sabrina’s adoptive parents, Marc and Misty Ray. The Perry couple parented foster children, adopted four children, and ran an in-home daycare. None of the 11 abuse reports was considered “founded” by the DHS staff.

In May 2017, when police found the body of Sabrina Ray inside the home of Marc and Misty Ray, the teenager weighed just 56 pounds and her body showed signs of severe malnutrition.

At the time, Sabrina’s adoptive parents were on their way to Disney World in Florida. Two other girls who were adopted by the Rays, ages 10 and 12, were in the room with Sabrina’s body when officers arrived at the house.

Police noted that an alarm had been installed on the door of the bedroom where Sabrina was found. A lock of some type had been on the door and then removed, screws were used to keep the windows from opening. There were also locks and alarms on food and beverage pantries in the kitchen and family room.

Sabrina’s adoptive parents were initially charged with first-degree murder, kidnapping and child endangerment. Misty Ray later pleaded guilty to charges of kidnapping, and Marc Ray pleaded guilty to charges of child endangerment and kidnapping.

Sabrina’s adoptive grandmother, Carla Bousman, was initially charged with first-degree kidnapping, child endangerment causing death and obstructing prosecution or defense. She was later sentenced to 20 years in prison after pleading guilty to a variety of charges, including neglecting a dependent person, obstruction of prosecution, child endangerment and false imprisonment.

DHS ‘intimately familiar’ with family before teen’s death

According to the ombudsman’s report, “DHS was already intimately familiar” with the Ray family before Sabrina’s death. The agency was involved with the Rays through the licensing of their home for daycare services; the agency had approved and licensed the Rays for foster care; and the agency had been the recipient of 11 child-abuse complaints involving Sabrina, her siblings and the foster-care children in the Ray home.

In the ombudsman’s report, Hirschman notes that current record-retention policies at the Iowa Department of Human Services hinder the ability of agency workers to identify patterns of abuse. That finding echoes those of the ombudsman’s February report on the death of another 16-year-old Iowa girl, Natalie Finn.

In the new report, Hirschman says “DHS’s failings in the Ray case were even more acute than with the Finns. In the Ray household, the mistreatment of children extended beyond the immediate family, to the parents’ in-home daycare and foster care children. Unlike the Finn case, where Natalie’s mother obstructed authorities’ attempts to inspect the home, DHS workers and contractors were regularly in Sabrina’s house and in contact with the family over a period of years.”

Hirschman says “suspicions of abuse were certainly present among those who interacted with children at the Ray household,” but a lack of communication among officials weakened the oversight that could have discovered the abuse that was occurring.

“We also found it unfathomable that DHS conducted no internal review of its own actions and decisions leading up to Sabrina’s death. We have renewed our plea to the Iowa Legislature to reevaluate its expectations for the Child Fatality Review Committee and other existing oversight bodies responsible for reviewing child deaths.”

Child Fatality Review Committee never convened

Twenty years ago, Iowa legislators approved a new law authorizing the creation of an ad hoc committee to investigate DHS-related child fatalities. The law specifically authorizes the state medical examiner to establish a Child Fatality Review Committee to immediately review child-abuse assessments that involve the death of an Iowa child to determine whether the Department of Human Services and others responded appropriately.

Since that legislation was passed in 2000, the committee has never been convened, the ombudsman’s report points out.

The report makes 13 recommendations to address the problems found by the ombudsman’s office and to strengthen Iowa’s child-welfare programs, 10 of which have been accepted by the Department of Human Services.

The report notes that one social worker — Shelby Messersmith, who worked for a DHS contractor called the Mid-Iowa Family Therapy Clinic — raised concerns about the Ray household but was “dismissed or silenced by her supervisors.”

Hirschman also states that an “undersized budget” at DHS contributed to the lack of rigorous oversight of key functions.

Among the other findings by the ombudsman’s office:

  • The Rays had a total of 23 foster care placements between 2006 and 2014, which resulted in four adoptions, including Sabrina’s. During the nearly 10 years the Rays were foster parents, their license was never suspended or revoked. The license was once placed on “hold” in April 2014, following a report that involved allegations of physical abuse and “denial of critical care.” The hold did not formally suspend or terminate the Rays’ license, but meant the couple would not receive any future foster care placements. Despite the hold, DHS kept three foster care children in the home
  • In August 2010, DHS received a report of alleged child abuse involving the Ray family. However, the department later expunged the intake and assessment records pursuant to its internal record retention policy, so the ombudsman was unable to determine who the reporter was, what type of abuse was alleged, or the outcome. The available records suggest that an assessment was completed in September 2010. Marc and Misty Ray were the alleged perpetrators and one of Sabrina’s sisters, then 5 years old, was identified as the alleged victim.
  • In September 2013, DHS received a child abuse report from Shelby Messersmith, who was handling services for children through a contract DHS had with her employer, the Mid-Iowa Family Therapy Clinic. The report involved a 16-year-old child living with the Rays, and Messersmith alleged the child’s Ritalin prescription was not being filled. She also reported that the Rays had called the child a “fat ass.” The complaint was rejected. A week later, Messersmith filed a new complaint concerning three adoptive children in the Ray home. The complaint relayed concerns that Marc and Misty Ray physically abused Sabrina and her sisters and withheld food from the girls as a form of discipline. That case was accepted by DHS and the Rays admitted to a field worker that they used physical punishment, but denied taking away the children’s food as punishment. The three girls denied that Marc and Misty physically abused them, and reported that they had plenty of food to eat in the home. The field worker reported the “children were observed to be thin but not abnormally thin.” That same month, another individual reported that Marc and Misty Ray were providing improper meals to their children, imposing improper discipline, and calling the children degrading nicknames. The complainant said Sabrina had become “extremely thin and withdrawn” and was “starved for social interaction.” An investigation was initiated by the state’s daycare licensing staff who later visited the Ray home and reported finding no evidence to support the claims.
  • Between April and November 2014, DHS received five child abuse complaints about the Rays. Three of the complaints were rejected and two were accepted for assessment. The first complaint came from a mother of a child who had been placed in the Rays’ foster home. She alleged Sabrina, then 13, and her sisters, then 9 and 7, weren’t being fed for weeks at a time and had to fight each other for food. She also alleged that Marc and Misty Ray physically abused Sabrina in the basement, and that there was video footage of one of these incidents. A DHS worker made an unannounced visit to the Ray home the same day the report was received and interviewed the girls, who denied that anyone had ever hit them or made them fight for food. A short time later, DHS officials decided to place the Rays’ foster care license on “hold” but opted to allow the foster children already there to remain. The ombudsman’s office says this decision to keep children in the Ray home following the hold was “unacceptable,” and the subsequent decision to keep them in the home after additional concerns were raised was “unfathomable.”
  • Messersmith made her third child abuse report to DHS in April 2014, alleging that one of the foster children in the Ray home was claiming Marc and Misty Ray were forcing him to eat food he did not like, which made him throw up, and that the Rays would not allow him to go to the restroom when he threw up, and instead made him throw up on his plate and eat it. Messersmith told DHS that Marc and Misty Ray no longer allowed her to come into the home when she dropped children off after visits. The complaint was rejected.
  • DHS received a child abuse report on May 7, 2014, from the adoptive parent of a former foster child who had lived with the Rays. The child had alleged she was subjected to certain punishments while staying with the Rays, such as drinking soapy water and water with spices in it, and standing all day either against a wall or over a cold vent. The child also alleged Marc and Misty Ray would make her go without meals and made her bite her sister while the Rays would laugh. The complaint was rejected.
  • In June 2014, Messersmith documented bruising on one of the foster children living with the Rays. Messersmith believed there was a strong chance that the bruising had been inflicted by the Rays, as the bruising was up the child’s back and thigh, not in common “play areas” such as a child’s knee. Messersmith stated that she went to her supervisor at Mid-Iowa, Susan Smalley, regarding the bruising on the child, but was told that she could not make a child abuse report to DHS. Messersmith later told the ombudsman’s office she had been verbally reprimanded for raising the concerns. “DHS not only dismissed Messersmith’s concerns, but, along with her supervisor at Mid-Iowa, actively discouraged her from speaking up,” the ombudsman’s report concludes.

Danger of abuse rises during pandemic

Noting that many Iowa children will be staying home from school this fall due to the COVID-19 pandemic, Hirschman says “the potential for child abuse to occur is much greater” when children fall aren’t being observed by conscientious and inquisitive school officials.

“I am fearful that those who try to hide abuse will now have an easier and greater opportunity to do so,” Hirschman wrote in the new report. “I cannot stress enough that we must all remain vigilant about identifying and reporting suspected child abuse, especially during these challenging and unsettling times.”

In the ombudsman’s report, Hirschman notes that while DHS Director Kelly Garcia was not working at DHS when Sabrina and Natalie died, “she has accepted responsibility nonetheless and has acknowledged the need for improvement by adopting most of my recommendations.”

Clark Kauffman
Deputy Editor Clark Kauffman has worked during the past 30 years as both an investigative reporter and editorial writer at two of Iowa’s largest newspapers, the Des Moines Register and the Quad-City Times. He has won numerous state and national awards for reporting and editorial writing. His 2004 series on prosecutorial misconduct in Iowa was named a finalist for the Pulitzer Prize for Investigative Reporting. From October 2018 through November 2019, Kauffman was an assistant ombudsman for the Iowa Office of Ombudsman, an agency that investigates citizens’ complaints of wrongdoing within state and local government agencies.