Pinellas County Sheriff Bob Gualtieri reports on an investigation Aug. 16, involving the death of a 5-year-old girl removed from her home and placed into foster care.
LARGO - A 5-year-old girl is dead, and now a woman has lost her job.
Elizabeth Holder died Jan. 19 at Mease Countryside Hospital in Safety Harbor. Pamela Wilson, a family support worker with Pinellas County Sheriff’s Child Protection Investigations Division, was fired Aug. 13 for lying to investigators.
Sheriff Bob Gualtieri announced results of an administrative investigation Aug. 16 and the agency’s review of policies and procedures surrounding the removal of children by the Child Protection Investigations Division and their timely health screenings.
Elizabeth was removed from her parent’s care Jan. 11. She had been living in a mobile home at 2381 Gulf to Bay Blvd. in unincorporated Clearwater that Gualtieri described as “dirty and unfit to live in.”
The sheriff’s office got involved when Child Protection investigators were called to the home after the child was found wandering around the mobile home park unattended. Her mother was arrested for child neglect and transported to the Pinellas County Jail.
Gualtieri said the mother was on non-prescribed prescription medications and unable to care of Elizabeth or her 2-year-old sister. The father, Corey Holder, came by the day of the arrest, but he too was on prescription medications and unable to take care of the children.
A decision was made to place the children in foster care. Eckerd Community Alternatives, who serves as the Community-Based Care Lead Agency for child welfare and foster care in Pinellas, Pasco and Hillsborough counties, was contacted to make arrangements for the two children.
Elizabeth and her sister were placed in foster care the evening of Jan. 11. At a hearing the next day, a judge ruled there was sufficient cause to remove the children from their home.
State law requires that a child removed from their home undergo a mandatory health screening within 72 hours. Gualtieri said on Monday, Jan. 14, a family support worker tried unsuccessfully to set an appointment for Elizabeth to receive a screening. Neither the health department nor a private provider who had treated the child in the past could see her that day. An appointment was set with the private provider on Jan. 22 – well beyond the 72 hours.
On Jan. 18, a week after the children were taken away from their parents, the foster parents took Elizabeth and her sister to a babysitter in Dunedin. The child went to bed about 9 p.m. and woke up about 8:30 a.m.
“She played, watched TV and she ate,” Gualtieri said. “About 4 p.m., she began screaming and holding her head. She said it hurt and asked that it stop hurting. She went limp and went into cardiac arrest. 911 responded and she was transported to Mease Countryside Hospital where about 5 p.m., she was pronounced dead.”
The medical examiner found no sign of trauma, Gualtieri said. The cause of death was endocardial fibrosis with a contributory condition of tonsillitis. Endocardial fibrosis is marked by a thickening of the lining of the heart chambers and is an uncommon cause of heart failure in infants and children.
After Elizabeth’s death, Gualtieri ordered a review of procedures and an investigation by Internal Affairs, who interviewed three Child Protection Investigations employees: Supervisor Sarah Pierce, Investigator Brett Edwards and Wilson.
The investigation concluded that none of the three was personally responsible for Elizabeth not receiving her health screening within 72 hours.
“It was a problem with procedure, it’s a system problem, not any one individual’s fault,” Gualtieri said.
He made it clear that Wilson lost her job not because of the failure of the child to receive the health screening but because she lied.
“It was not because of what she did or did not do with the 72-hour health screening,” he said. “During the investigation Pam Wilson lied and I’m not going to tolerate people lying to our Internal Affairs investigators or lying period as an employee of the Pinellas County Sheriff’s Office or lying period as an employee of the Pinellas County Sheriff’s Office, and especially to these subsequent matters.
“This is not the first time. In fact it is the second time in the course of her 30-year career here at the Pinellas County Sheriff’s Office that Pam Wilson has had a substantiated complaint of being untruthful.”
Wilson began working for PCSO July 25, 1983. The prior complaint involved being untruthful about the unauthorized use of an agency issued vehicle that was stopped by law enforcement in Tampa.
In the case of Elizabeth Holder, Wilson gave a variety of substantiated and unsubstantiated reasons why she didn’t do her job properly, including having a migraine headache, working a partial shift, working overtime, having another case, not knowing procedure and others.
The state requires documentation about children who are removed from the home to be entered into a state-run computer system within 24 hours.
“She didn’t do it and during the investigation lied several times about why she did not do it,” Gualtieri said. “I’m not going to tolerate it. Pam was terminated because of untruthfulness, not because she didn’t set an appointment (for the health screening).”
Problems with the system
Gualtieri said the review of procedures and protocols showed a variety of problems.
“Unfortunately this is not the first time we had not ensured that the 72-hour health screening was completed,” he said. “In fact, the investigation revealed this happened many times.”
In 2012, PCSO investigated more than 11,000 cases of abandonment, abuse and neglect allegations. Gualtieri said every year for the past several years, investigators had looked into more than 11,000 allegations.
“The numbers are up this year and we’re on track to investigate between 14,000 and 15,000 allegations of abuse, abandonment and neglect,” he said.”
Of the 11,000 cases in 2012, 884 resulted in children being removed from the home. In 238 cases, it was not possible to tell if the health screening was done or not. The sheriff explained that the Family Support System is the state’s computer system that Child Protection employees are required to use to document their actions.
“There’s no field to enter the data to indicate whether the screening was done or not done,” he said.
Employees used the notes section, which is not searchable by the computer.
“We had to manually search and by hand review every one of the 884 cases in 2012 to review these cases, and digging into them we were unable to tell whether they (health screenings) were done or not,” Gualtieri said. “They might have been done. They might have been timely, or they might not have been timely or it might not have been done at all. I can’t tell you.”
He said of the 664 cases, it was confirmed that the screenings complied with law 279 times or in 43 percent of cases, another 198 were not done in a timely basis and 169 were not required to have a screening, for reasons including become a part of the foster care system at birth or while in the hospital. Of the 477 screenings that were done, 58 percent were one within 72 hours and 41 percent were not.
A number of reasons and factors contributed to the problem, he said. One cause is the ambiguity of the language in the contract between PCSO and Eckerd that says the health screening must be initiated within 72 hours, not completed. Eckerd’s agreement with the state says Eckerd must do the screenings.
“Let me make it clear, this is not Eckerd’s responsibility. Under the law, it says it has to be done but it does not say who has to do it,” Gualtieri said.
He said because PCSO contracts with Eckerd for services it is ultimately the sheriff’s responsibility.
“At the end of the day, it falls on us period. It doesn’t fall on anyone else,” he said.
Another problem was getting immediate access to health care providers for appointments. He said the employee who made an appointment for Elizabeth with a health care provider who had seen the child in the past was a good thing. A preference within the system is for the kids to be evaluated by someone who has familiarity with the kid, he said. But the delay in the appointment past 72 hours did not comply with the law.
“So when you start putting it all together, it is a series of things that contributed to it (the health screening not being done),” he said.
Fixes to the system
Child Protection Investigations employees now have purchasing cards to use to pay for health screenings. The children can be taken to a walk in clinic, emergency room or any other health care provider to make sure the health evaluation is done in accordance with the law.
“We really broadened the scope of the network where we can get the screening,” Gualtieri said.
PCSO also has cleared up the “lack of clarity” in internal policies to make it understood who is responsible for making sure health screenings are done. The agency is also working toward better supervision and training for support workers.
“We’re taking remedial action to fix all these details,” Gualtieri said. “I take complete responsibility for this. It is something we should have done.
“The ultimate question that I don’t know the answer to and nobody knows the answer to and may not ever know the answer to, is whether the failure to conduct the 72-hour health screening would have made a difference.”
Gualtieri said he did not know of any other case, even arguable, where the lack of a health screening adversely affected a child.
“I really don’t know as we stand here today whether the failure to complete the health screening would have made a difference,” he said. “… If she had such a severe case of tonsillitis and it contributed to her death through the endocardial fibrosis and we had done the health screening within 72 hours and some physician had, as a result of the health screening, put her on antibiotics, by that Friday would it had made a difference, I don’t know,” Gualtieri said. “But if it was viral, the antibiotics would have made no difference at all.”
Gualtieri said no further details would be available, as litigation has started.
“The father is represented by a lawyer,” he said.
However, he did say the investigation would continue and PCSO was moving forward to make sure sufficient protocols were in place for the future.
“But putting all that aside, putting the law aside, putting aside the whole issue of whether it was bacterial or viral or whether it (the health screening) would have made a difference, we should have done it and made sure she received a health screening,” he said. “It would be a nonissue if we had accomplished that.”