STATE CHILD FATALITY REVIEW

FINDINGS AND RECOMMENDATIONS

CATAWBA and CALDWELL COUNTIES
August 21-24, 2012

Prepared by:
Division of Social Services

Baker

State Child Fatality Review

Catawba County
August, 2012
A State Child Fatality Review Team composed of the Catawba County Child Protection Team,
Catawba County Department of Social Services, Caldwell County Department of Social
Services, North Carolina Division of Social Services staff, law enforcement, and other
community agencies met on August 21-24, 2012, to review the death of Zahra Clare Baker.
Since her family had been involved with the Catawba Department of Social Services within the
twelve months preceding Zahras death, an in-depth review was conducted pursuant to
General Statute 143B-150.20. According to paragraph (b) of the statute,
The purpose of these reviews shall be to implement a team approach to identify
factors which may have contributed to conditions leading to the fatality and to develop
recommendations for improving coordination between local and state entities which
might have avoided the threat of injury or fatality and to identify appropriate remedies.
Toward this end, a State Child Fatality Review Team was appointed with community
representatives as required by state law. Persons attending the Review were:
Name
Gail Henson
Karyn Yaussy
Jennifer McCracken

Bobbie Sigmon
Jennifer Bowman

Jill Duffy
Roslyn Thompson

Daphne Green
Capt. Joel E. Fisher, Jr
Faith Lee
Katie Turk

John Eller
Joyce Edwards
Beth Brandes
Baker

Agency Title
Catawba County Schools
Catawba County Emergency
Services
Catawba County Public Health

Catawba County Department of

Social Services
Program Manager, Caldwell
County Department of Social
Services
Caldwell County Schools
Childrens Program
Representative, NC Division of
Social Services
Program Administrator, NC
Division of Social Services
Catawba County Sheriffs Office
Child Fatality Reviewer, NC
Division of Social Services
Program Manager, Catawba
County Department of Social
Services
Director, Catawba County
Department of Social Services
Director, Caldwell County
Department of Social Services
Assistant Director, Catawba
County Department of Social
Services

Role on Team
Prevention Representative
Medical Representative
Community Child Protection/Child
Fatality Prevention Team
Representative
County Department of Social
Services Representative
County Department of Social
Services Representative
Prevention Representative
NC Division of Social Services
Representative
NC Division of Social Services
Representative
Law Enforcement
Representative
Facilitator
County Department of Social
Services Participant
County Department of Social
Services Participant
County Department of Social
Services Participant
County Department of Social
Services Representative
2

The Team reviewed relevant, available records, including those from law enforcement, first
responders, medical providers, and health and social service agencies. The Team also
interviewed persons who were believed to have relevant information helpful to formulating
findings and recommendations. The timeline was completed and the nine life domains
(safe place to live, family, emotional/psychological, vocational/educational, physical health,
legal, safety/crisis, social life/supports, and cultural/ethnic) were discussed.
Zahra Baker was born on November 16, 1999, however, the exact date of her death could
not be determined. The decedent was a 10 year old female, whose medical history
included a d i a g n o s is o f osteosarcoma in 2 0 0 5 , wh i ch resulted in her left leg being
amputated above the knee. In 200 7, Za hra a lso underwent a right lung lobectomy when
the cancer spread. I n l a t e 2 0 0 8 , s he moved from Australia to the United States with
her father and step-mother. Since her arrival into the United States, m edical records of any
treatment are sparse and fail to reveal any major health problems. I n O c t o b e r 2 0 0 9 ,
a chest radiograph showed no evidence of neoplastic disease.
Prior to October 2010, four child protective services reports were made in response to
allegations of maltreatment to which two county departments of social services completed
assessments, Caldwell and Catawba. These reports are dated January 29, 2010, February
4, 2010, May 28, 2010, and July 12, 2010. The February 4, 2010 report was received while
the January assessment was just beginning so the additional allegations and information
were included into the already active assessment. On October 11, 2010, a report was made
by her father and step-mother to the Hickory Police Department and Catawba County Social
Services when Zahra was determined to be missing. According to the initial report to the
Hickory Police Department, the father and step mother stated that Zahra had been abducted.
Later, It was determined that Zahra was deceased and her body had been dismembered
and her remains were disposed at various locations.
According to the Office of Chief Medical Examiners report, the cause of Zahras death was
undetermined homicidal violence. An autopsy completed on the partial skeletal remains
of a sub-adult human c o n f i r m e d , t h r o u g h DNA testing, that the remains were those
of Zahra Baker. Several of her bones also exhibited cutting tool marks that are consistent with
dismemberment. Further, two of her right ribs exhibited healed remote fractures which may
be the result of prior surgical intervention. There w a s no evidence of bony neoplastic
disease.
In September of 2011, Elisa Baker was sentenced to 18 years in prison after pleading guilty
to the second degree murder of her 10-year-old stepdaughter, Zahra Baker.
Immediately following Zahras disappearance, the Caldwell County and Catawba County
Departments of Social Services conducted separate internal reviews of child welfare
practices and processes. These reviews resulted in conversations with community partners
toward enhancing and strengthening the service delivery system for children and families
within the agencies and in their respective counties. Many of the strategies developed in those
reviews and community conversations helped to shape the Review Teams findings and
recommendations.

Baker

FINDINGS AND RECOMMENDATIONS

During the Review, the Team examined the circumstances surrounding Zahras death to
develop findings and recommendations for further action.
Finding 1:
The school personnel with Caldwell County Schools were attuned to Zahras needs
and were persistent in trying to resolve those needs, utilizing team collaboration among
school personnel to provide comprehensive services to Zahra.
There were some concerns among school personnel about Zahras needs being
met that were not reflected in formal reports made to Caldwell County Department of
Social Services.
Recommendation 1:
The Caldwell County Community Child Protection Team will develop and implement
community training on reporting suspected child abuse and neglect to the county
department of social services.
The Caldwell County Community Child Protection Team, the Caldwell County
Department of Social Services and the Ca ld we ll Cou nt y S cho ol S ystem will
provide in service education to ensure t h a t school personnel are aware of when and
how to report suspected child abuse and neglect.
Caldwell County Schools will continue to develop with Caldwell County Department of
Social Services their process to share information to assure child protective service
assessments are comprehensive.
Caldwell County Schools will evaluate the feasibility of assigning a point person once
a child protective services report has been made to collect information in order to
support the assessment process.
The North Carolina Department of Public Instruction and the North Carolina Division of
Social Services will review the Memorandum of Agreement which establishes a protocol
for providing concurrent child welfare services by the two agencies and consider
revising the section that permits a school to have a designee make child protective
service reports to departments of social services in place of the person having first-hand
knowledge of child safety issues.
Finding 2:
The parent and caretaker purported to use home schooling, in order to hide their
maltreatment of Zahra. There is no indication that an application t o home school
Zahra was ever actually made.
There is no coordinated means to track children when they move to another school
system or an alternative educational plan.
The Compulsory Attendance Law does not require parents to provide relocation
information or an educational plan when the child is withdrawn from school.
Currently, there is no other known code or policy in place regarding time frames in
which parents or custodians must notify the school from which children are withdrawn
of their enrollment in another school or verify another educational plan.
Recommendation 2:
The North C a r o l i n a D e p a r t m e n t o f P u b l i c I n s t r u c t i o n s h o u l d
o d e v e l o p a live state system for tracking children when they are enrolled in
school, are not present at the beginning of the school year, or are withdrawn
Baker

from school;
o establish a timeframe in which parents must notify the school from which
the child was withdrawn of the childs enrollment in another school or other
approved educational plan;
o set time frames within which schools must request records from childrens
previous school in addition to setting a response time to another schools record
requests.
The North Carolina Division of Non-Public Education should:
o issue home school certificates for all home school plans.
o require a criminal background check on administrators prior to approving a
home school certificate, including use of Social Security numbers to control for
any aliases.

Finding 3:
The North Carolina Division of Social Services in collaboration with county
departments of social services developed a structured child protective services intake
form for uniformity of decision-making across the state.
Decisions at intake are based upon information provided by the reporter and
documented in the structured intake format.
The child protective services structured intake form does not have a distinct field for
entering information regarding the alleged perpetrators numerous aliases, previous
child protective services involvement known to the reporter, or the names of adult
children which would be helpful in identifying any previous child protective services
involvement..
Departments of social services are only able to review county records regarding child
protective services history when determining if a report meets all the definitions for
assessment. There is no immediate access to information sources such as child
protective services reports in other counties, the National Criminal Records database,
or cross matching alleged perpetrators across other databases
Recommendation 3:
The North Carolina Division of Social Services, in collaboration with the North
Carolina Association of County Directors of Social Services, will evaluate whether the
child protective services structured intake form needs to include fields for previous child
protective services involvement, all former names or aliases of the parents and
caretakers, along with the names of the parents or caretakers adult children at the
time of the report.
Within the confines of existing law, the North Carolina Division of Social Services will
evaluate the efficacy of broadening the scope of information available to assist in
assessing child risk when determining if the report meets all the statutory criteria to
intervene with an assessment.
Finding 4:
On January 29 and May 28, 2010, Caldwell County Department of Social Services
received child protective services reports alleging neglect of Zahra.
In regard to the January 29, 2010 report, Caldwell County Department of Social
Services met policy requirements by initiating family contacts and home visits within
time frames to begin the assessment, and they completed some collateral contacts as
prescribed in policy.
In regard to the February 4, 2010 report, Caldwell County Department of Social
Baker

Services, as directed in policy, combined the information from the new report into the
already initiated assessment regarding the January 29, 2010 report.
There were important pieces of information missing at the time case decisions were
made at the completion of the assessment. This information could have been obtained
if the following activities had been completed:
o verification of medical information on the childs injury and current medical
status;
o addressing all the allegations in the original report;
o additional inquiry regarding the impact of prescription drugs usage by parents and
caretakers;
o identifying the prior child protective services history of all caretakers;
o interviews with absent parents or caregivers; and
o interviews with additional persons who had knowledge of the Zahras well being.
In regard to the child protective services report received on May 28, 2010, Caldwell
County Department of Social Services in the child protective services assessment
conducted timely visits to the home and interviewed the child privately.
Additional actions by Caldwell County Department of Social Services may have
ensured that all relevant information was secured during the May 28, 2010
assessment, including:
o screening the reported injury as an abuse report and conducting an
investigative assessment requiring a more forensic approach rather than a family
assessment which is typically completed for neglect reports;
o conducting a face-to-face interview with the father;
o verifying medical information provided by caregivers regarding Zahras injury and
current medical status, including arranging for a physical examination of Zahra
by a physician;
o photographing the physical injury that was reported;
o making diligent efforts to locate and interview all family members with
relevant family history information;
o accessing and reviewing the child protective services documentation of
findings from the January 29, 2010 assessment;
o obtaining the child protective services history of all caretakers; and
o contacting absent parents and caregivers,
In addition, some administrative issues were identified regarding the conduct and
management of the assessments, including:
o the level of supervisory oversight needed to be stronger and more direct;
o documentation of communication with collateral contacts made during the
assessment needed to be clearer; and
o assumptions made during the assessment gave the appearance that c h i l d
p r o t e c t i v e s e r v i c e s case decisions were not as objective as they should
have been.
There was limited collaboration and communication between community partners
(school personnel, medical providers, and law enforcement) resulting in critical
information not being considered in the child protective services assessment.

Recommendation 4:
The Caldwell County Department of Social Services should continue to monitor,
evaluate and update the plan to improve service protocols, case tracking, monitoring,
and supervisory oversight developed during an internal investigation following the
fatality.
Baker

The Caldwell Community Child Protection Team, as an accountability partner, should

periodically evaluate with Caldwell County Department of Social Services the progress
in implementing changes from the Departments internal reviews.

Finding 5:
Catawba County Department of Social Services met policy requirements by
ensuring that an after- hours worker responded to the home within prescribed time
frames, met initiation requirements by ensuring all contacts were made with the
child and family, completed the safety assessment with the family and interviewed the
child separately.
The after-hours social worker ensured documentation was submitted the same day
of initiation. Criminal records check and central registry history were requested in
the July 28, 2010, child protective services assessment.
During the July 28, 2010 assessment, additional actions were needed to ensure that
all relevant information was secured, including:
o verifying medical information to explain the childs injury and current medical
status;
o making efforts to ensure a l l collateral contacts w h o h a v e r e l e v a n t
information were interviewed beyond those named in the original report, such
as school personnel or verifying home school enrollment;
o ensuring that the multiple workers contacting the collateral contacts
debriefed together regarding the information they gathered;
o thoroughly assessing substance abuse allegations and prescription drug
usage;
o making attempts to contact absent parents/caregivers;
o conducting adequate research on the origin of the bruises on the child;
o assessing the potential for violence within the family; and
o evaluating criminal records and the central registry history of the caretakers.

There is no protocol for county departments of social services to search for child
protective services history beyond North Carolina.
Recommendation 5:
Catawba County Department of Social Services will continue t o implement and
evaluate the plan for enhancing casework that was developed from an internal review,
including outlining child protective services training essentials and having supervisors
observe child welfare workers in the field.
Catawba County Department of Social Services will continue to evaluate the need
to restructure training plans for child welfare staff to address the ever changing needs
of families.
The North Carolina Division of Social Services will include in policy instructions for
securing child protective services history information from jurisdictions other than North
Carolina.
Finding 6:
Policy is established in North Carolina to provide guidelines for adhering to statutory
responsibilities and best practice to assure a measure of consistency across all
counties.
Policy provides basic requirements which local departments can enhance as the
local need becomes evident;
Prior to issuing new policy, the North Carolina Division of Social Services consults
Baker

with the directors of the county departments of social services to establish a balance
between being prescriptive and providing flexibility for professional discretion in county
departments of social services, so service plans w i l l b e t a i l o r e d to
address the specific safety, permanence, and well-being needs of children and their
families.
There are no restrictions in policy on county departments of social services
requiring additional staff activities beyond those basic requirements prescribed in
statute, rule, and policy.

Recommendation 6
The North Carolina Division of Social Services will explore with the directors of
county departments of social services additional requirements during child
protective service assessments, including:
o a contact made with a teacher or other school employee who has direct
contact with a school age child on a daily basis;
o social workers identifying and contacting any other individual who may have
critical information on a child within the school (nurses, school resource officer,
principals, social worker, counselors);
o a collateral contact with the childs school within two weeks of the start of
school year if there is an open child protective services assessment;
o verification in the case file of consultation with medical personnel if there are
allegations regarding a childs medical needs being met; and the establishment
of time frames for county departments of social services to respond to requests
for child welfare records and information by other county departments
of
social services completing child protective service assessments;
o photographic and/or written documentation of social worker observations when
there are allegations of abuse or when there are injuries found on a child which
may be the result of maltreatment.
The North Carolina Division of Social Services should mandate t h a t new child
welfare social workers be provided a graduated increase in cases assigned up
to the caseload standard over a three month period after Pre-Service Training
is completed.
Finding 7:
Currently, a statewide automated child welfare case management system is not in
existence.
A Central Registry under General Statute 7B-311(a) is
available to track children who have been maltreated in North Carolina, but its
use is significantly restricted.
County departments of social services do not have access to information regarding the
existence or nature of current or prior child protective service reports in North Carolina
when evaluating reports to determine if the statutory requirements are met to initiate an
assessment.
Any statewide system software should have the capacity for:
o Attaching files for medical information and photographs;
o Cross referencing children, parents, and other relatives; and,
o Have multiple search functions.
Any statewide system should include access to
o NCWISE (school database);
o Department of Public Instruction database;
o CAD Reports (911 logs);
Baker

o
o
o
o
o
o
o
o
o

Administrative Office of the Courts (criminal record checks);

OnLine Verification (for all 100 counties);
North Carolina Controlled Substances Reporting System;
Department of Juvenile Justice (DJJ);
Department of Public Health (Health Information System);
Central Registry;
NCTRACKS (Medicaid Management Information System; and,
North Carolina Division of Non-Public Education.
Links to other data systems determined to be an asset in assessing child safety.

Recommendation 7:
The North Carolina Department of Health and Human Services should expedite
the development and implementation of a statewide case management and
documentation system for the child welfare continuum of services. This would include
o access when receiving a child protective service report to current and prior child
protective services reports and interventions;
o the National Criminal Records database; and
o connection to other public assistance systems using multiple identification
numbers and sources.
When this electronic system is implemented, the North Carolina Division of Social
Services should ensure, within the limits of the software, a fully integrated system with
the current legacy system and other databases.
Finding 8:
The concern was expressed that parts of the Child Welfare in North Carolina Preservice Training could be perceived to give priority to being family friendly versus safety
centered in child protective services assessments.
Through the website ncswLearn.org, the North Carolina Division of Social Services
makes available information on all training requirements for social workers and
supervisors in child welfare and other service areas, including requirements for job
specific training and the time frames in which social workers and supervisors are
required to complete them.
The current Child Welfare in North Carolina Pre-Service Training includes a transfer of
learning element to assure that supervisors play an active part in the social workers
initial training.
The North Carolina Division of Social Services encourages participation of county
staff members in monthly webinars and periodic regional meetings focused on
addressing practice concerns and providing a forum for feedback.
Recommendations 8:
The North Carolina Division of Social Services will review the curricula for Child
Welfare in North Carolina Pre-Service Training to assure a clear emphasis on safety
needs of children in the family centered practice model.
The North Carolina Division of Social Services should review the overall curricula of
the Child Welfare in North Carolina Pre-service Training to determine if additional
elements should be added to improve the effectiveness of the training.
The North Carolina Division of Social Services will explore means to provide county
departments of social services data on the training activity of their staff.
The North Carolina Division of Social Services should consider utilizing training staff
from local departments of social services to assist in providing Pre-Service and job
Baker

specific training.
Catawba County Department of Social Services should encourage staff t o participate
in webinars and other information activities on family centered practice and develop
ways and means to assure social workers and supervisors maintain efficacy in
providing family centered services.

The Review Team developed these recommendations as guides to improve local systems of
care and highlight areas in which it is believed services could be improved for children and
families state wide to better protect children in the future. However, it cannot be known
what impact, if any, these recommendations could have had on this case had they had been
in place at the time of the fatality.
Representatives of the Division of Social Services will follow up within 6 months of the release
of this report to review progress in implementing the local changes.
The Division of Social Services appreciates the time and commitment to this process from
the Community Child Protection Teams and Child Fatality Prevention Teams and other
community agencies in Caldwell and Catawba Counties. It is an expectation that changes
in policies and practice resulting from this report will improve future service provision to
enhance the safety, permanence and well-being of children and families.

Baker

10