Louisiana Office of State Inspector General issues report on fentanyl death of child

Michael Scheidt
·8 min read
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BATON ROUGE, La. (BRPROUD) — The Office of State Inspector General cites several failures on the part of the Louisiana Department of Children and Family Services and others leading up to the fentanyl overdose death of 2-year-old Mitchell Robinson III in a new report.

He died on June 26, 2022, and the OIG found that DCFS was called twice by a registered nurse at Our Lady of the Lake North emergency room on April 12 and June 4, 2022.

The mother of Mitchell Robinson, III, Whitney Ard, was charged with second-degree murder in connection with the toddler’s death. She would later plead not guilty to the murder charge. The case is still pending.

OIG said “there is no factor more significant than the critical nine-day period between June 17, 2022 and June 26, 2022, during which DCFS personnel, including the assigned case worker and supervisor, had specific knowledge that Mitchell Robinson III had tested positive for fentanyl at the time of his June 4 hospital admission. During those nine days, DCFS personnel took no
action whatsoever to ensure the safety of the child.”

Here’s the timeline OIG pieced together of what happened to Mitchell in the weeks leading up to his death, how DCFS responded and why. DCFS also explained what is being done to help other kids in similar situations get the help they need faster.

ER visits lead to DCFS calls

On both dates, the child was given Narcan after arriving at the hospital unresponsive. He responded and received more treatment at Our Lady of the Lake Children’s Hospital each time.

The first time, he wasn’t breathing and responded to four rounds of Narcan. A drug screen, however, was negative. The nurse added a follow-up written report calling it a “possible drug overdose.”

On the June 4 report, according to the OIG, a nurse said he wasn’t breathing well and only responded to narcotic reveals meds. He reportedly responded well to Narcan the first time but not the second or third doses. Again, his drug screen was negative.

“The nurse informed the call-taker that ‘This is not the mother’s first time bringing this child in for this’ but when asked if she could ‘pull up the chart and give me a synopsis about the last time,’ she replied that she could not,” the report reads.

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The hospital did not contact law enforcement, and no written report was submitted after the second call.

“It was determined upon initial review by a DCFS Intake Supervisor that the reports did not meet their criteria to initiate an investigation,” according to the OIG.

On June 6, a doctor and social worker at Children’s Hospital reached out to DCFS because Mitchell was about to be discharged and sent home.

A DCFS supervisor recognized that the child’s response to Narcan was significant. Internal emails showed employees acknowledged he accessed a narcotic the hospital may not test for.

On June 7, the case was assigned as Priority 2, and the caseworker was meant to contact the client within 48 hours.

A children’s hospital doctor called DCFS on June 17, explaining that the drug screen from Mitchell’s admission on June 4 was positive for fentanyl. She wanted to see what action DCFS had taken to help the child and ordered extra blood tests to check for the drug.

The physician said he had “overdosed in his own house twice” and “went home with parents who nearly killed him twice.” The physician stated she “would like to get this kid somewhere safe,” according to OIG. She noted a May 2022 drug bust at the child’s house and said Narcan only works on opiates.

The OIG report said Mitchell Robinson, Jr. and Whitney Ard “were arrested and booked on numerous felony drug charges” on May 11, 2022. There was no record of a call to DCFS regarding the couple’s young children, the OIG noted.

The DCFS worker said they would “take another report,” according to OIG. The information was forwarded to the caseworker.

The caseworker “was assigned several other high-priority cases during the same critical period of time,” OIG said. They got sick, and no DCFS employee met with the parent or child before his death.

DCFS declined to investigate

DCFS released an initial report following an investigation into Mitchell’s overdose death, and then DCFS Secretary Marketa Walters, Assistant Secretary of Child Welfare Rhenda Hodnett and others met with the OIG to provide a timeline for its report.

The intake supervisor said the lack of illegal drugs in the drug screen was giving a lot of weight to the decision not to investigate, and at one point, a possible seizure disorder was discussed.

“Those who determined that the reports would not be accepted for investigation apparently understood the negative drug screen to show that the child had no illegal drugs in his system and that there must be some medical explanation for his condition. It was acknowledged that Centralized Intake employees had received no training regarding the medical use of Narcan,” the OIG wrote.

The caseworker said she was assigned the case on June 7 while working a Priority 2 sex abuse case. The Mitchell Robinson case was already outside the 48-hour contact window by the time she’d been given it because of the delay in opening the file. She was out of the office on June 8 and then was instructed to stay in the office and work on a case backlog on June 9 and 10.

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She reportedly started working on the case on June 14 and left a call-back letter at an apartment on Greenwell Springs Road provided at the ER. She got a call back from Ard and set up a meeting on June 16.

After working all night and into her next work day on June 16, she was told to go home after wrapping up the paperwork on a case that required children to be taken into custody.

The meeting with Ard never happened.

State offices were closed on Friday, June 17, for Juneteenth. The caseworker responded to three calls that day and worked the next two days through the weekend despite being ill.

She went on sick leave June 20-24 and returned to work Monday, June 27.

Mitchell died on June 26.

The supervisor over the case resigned in August 2022. DCFS stripped her responsibilities immediately after Mitchell’s death, and she was on medical leave until her resignation. She did not speak with OIG investigators.

OIG says multiple failures led up to the child’s death

OIG concluded that multiple factors played a part in the death of Mitchell Robinson III including “multiple failures by DCFS Child Welfare management, especially the caseworker’s immediate supervisor.”

  • Overburdening one person with assigned cases requiring prompt contact.

  • Failing to help or mitigate the caseload.

  • Not checking that initial in-person contacts were made in newly-assigned cases.

  • Not handling the caseworker’s assigned cases while she was out on sick leave for a whole week.

  • DCFS intake personnel were not trained on the medical use of Narcan, so they didn’t know how important it was that the child responded to treatment.

  • Medical personnel did not contact law enforcement.

  • The hospital toxicology screens did not look for synthetic opioids. This led to misleading “negative” results.

  • There is no record that law enforcement contacted DCFS after two adults were accused of having drugs near young children in May 2022.

  • Medical personnel and DCFS had poor communication during the first two hotline calls.

Current DCFS explains changes to help more kids

DCFS Secretary David Matlock said he stepped into the role earlier this year during the regime change to Gov. Jeff Landry’s administration. He responded in a letter to the OIG and explained what they’re doing differently to help other kids get help sooner.

He said Mitchell Robinson III’s death is “truly a tragedy.”

In June 2022, he said, most people didn’t know how fentanyl would affect young children.

“At that time, it also was not widely known that a person would only respond to Narcan if an opioid were present and that negative drug screens do not necessarily point to the absence of drugs in the system. Even today, typical general drug screens in emergency rooms do not test for fentanyl,” Matlock said.

The child welfare division now specifically requires testing for fentanyl if a child is treated with Narcan.

A new policy also requires all reports of abuse or neglect from medical staff for kids three and younger to be accepted for investigation unless a manager overrides it.

DCFS also made changes to “stabilize and increase the capacity” of available employees. Case assignment has been streamlined, Matlock said, with more visibility around how many new cases are going to each worker and re-assign them as needed to distribute resources better.

He said the report underscores the “overwhelming workload and schedule that our staff are juggling.” In state fiscal year 2022, he said, there were 18,032 investigations. In 2023, there were 25,862, a 43.4% increase. He said 75% of cases now need in-person contact within 48 hours.

The department, Matlock said, is still understaffed and needs more caseworkers.

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