Agencies' failure cited in girl's case

Twelve-year-old Haleigh Poutre was nearly killed by chronic child abuse and then almost died from a premature decision to remove life support, because flawed or insufficient information was given to the state agencies, medical centers, and court systems that were supposed to protect her, a governor's investigative panel said yesterday.

''Child protection service does not exist in a vacuum," said Christine Ferguson, the state's former public health commissioner, who led the three-member panel. ''Haleigh's case represents a frightening confluence of a healthcare system ignorant of abuse and a child-protection system ignorant of medicine."

To avoid other tragic cases like Haleigh's, the state Department of Social Services needs more help and expertise to track complex abuse cases and needs a more stringent process to weigh end-of-life cases, the panel concluded.

Governor Mitt Romney, who appointed the panel, and DSS Commissioner Harry Spence said they would work together on the recommendations.

Neither Romney nor Ferguson singled out individuals or agencies for blame at a State House press conference yesterday, and the governor repeated his support for Spence's leadership at DSS. Instead, Romney and Ferguson blamed ''systemic failure" and said complicated cases such as Haleigh's -- in which there were more than a dozen reports of suspected child abuse and multiple therapists and doctors reviewing her case -- should be automatically flagged for high-level comprehensive review.

Romney's most pointed criticism was of the state's little-scrutinized procedure for deciding when to withdraw life support for a child in custody, saying the system is clearly inadequate.

Spence issued a statement yesterday, saying he was grateful for the panel's work and agreeing that closer collaboration among agencies is needed. He has consistently defended his staff's work on this difficult case. He also said the agency is continuing its care of Haleigh, who has emerged from her vegetative state but is still severely disabled. She has been in a Brighton rehabilitation hospital since late January.

The panel's report is the latest development in a dramatic case that has highlighted weaknesses in how the state cares for some of its most vulnerable children, from investigations of abuse to decisions on removing life support.

Haleigh's nearly lifeless body was brought to a Westfield hospital in September by her adoptive mother and stepfather, setting in motion a series of horrifying realizations by the state.

Within hours, DSS realized that its social workers had mistakenly accepted the adoptive mother's explanation that Haleigh had given herself the many bruises and burns over the years because she had a mental disorder. Some therapists had backed her adoptive mother's view. Two days after Haleigh was hospitalized, DSS took custody of the girl, and a week later, it backed police in charging the Westfield couple with the brutal assault.

In a bizarre twist, the adoptive mother, Holli Strickland, died in what police believe was a murder-suicide with her grandmother, two days after being charged with child abuse.

Six days after taking custody of Haleigh, DSS started down the path toward what it now acknowledges was another profound error, seeking to remove her life support at the initial suggestion of the child's lawyer, according to the panel.

The request was made based on medical opinions solicited from two doctors who were colleagues at Baystate Medical Center in Springfield, where Haleigh was moved after being brought to the Westfield emergency room.

The doctors testified that she was in a vegetative state with severe brain injuries and would probably never think or feel again. One of the doctors favored removing both her ventilator and feeding tube, and the other, for reasons that are unclear, wanted her feeding tube to remain, the panel found.

On Oct. 5, Juvenile Court Judge James G. Collins in Holyoke issued an order allowing all life support to be removed. But that order was stayed when the girl's stepfather, who would face murder charges if the girl died, appealed the decision.

Collins's ruling was affirmed by the state's highest court Jan. 17. The next day, however, DSS disclosed that Haleigh was breathing on her own and showing significant improvement. The next week, Haleigh was transferred to Franciscan Hospital for Children in Brighton.

The governor's panel is the first outside review of Haleigh's care. Other members of the panel were Dr. Mary Anne Badaracco, chief of psychiatry at Beth Israel Deaconess Medical Center, and Dr. Jeffrey Burns, chief of critical care at Children's Hospital Boston.

A second review is being conducted by a legislative committee that, unlike the governor's panel, has subpoena power.

Romney said yesterday that he believes most of the recommendations can be implemented without additional funds, though he was open to adding money if needed.

One recommendation that will go forward immediately, he said, is requiring DSS to solicit the opinions of two doctors from different hospitals, as well as a review by the child's hospital's ethics committee, before recommending to end the life of a child in the agency's care. He said the current system requires only one medical opinion and no mandatory review by the hospital's ethics panel.

''The process of deciding to remove life support for a child in state custody has been inadequate," Romney said. ''We must implement a far more comprehensive and robust process."

One shortcoming of the report, said one child advocate, was its failure to specify what errors were made in Haleigh's case and how the panel's recommendations would have made a difference. ''You need to have a more specific chronology of what happened," said Marylou Sudders, president of the Massachusetts Society for the Prevention of Cruelty to Children.

Ferguson, who had access to Haleigh's voluminous medical records, declined to answer questions about whether she believed that if all the information had been shared, DSS would have known that Haleigh was being abused and was not hurting herself.

She also declined to say whether the Baystate doctors had reason last fall to believe Haleigh's prognosis was hopeless.

Ferguson and the governor reiterated the need for looking ahead, not analyzing the details of the past.

''It's about systems changing," she said ''It's about moving to the next level."

Patricia Wen can be reached at wen@globe.com.