QUINCY -- An inspector general's investigation into Illinois' child welfare agency after the October 2018 deaths of two Quincy children found multiple lapses in the department's ongoing investigation with the family that started more than six months before the blaze.
This includes an investigator with the Department of Children and Family Services not going inside the home at 611 N. Eighth for a required visual inspection and multiple failures in following up in the case.
After the Oct. 12, 2018, fire that killed Toby Brewer, 8, and Emma Kramer, 5, fire officials found extension cords hand-spliced together with masking tape, including one placed under a mattress, which were later determined to be the cause of the fire.
The family was supposed to vacate the home in September 2018 and was squatting there. There was no electricity or other utilities to the home, and the extension cords were used to receive electricity from a neighboring home.
One of the family's two other children later told fire investigators that the cords would "snap and pop and smoke" and that they would hold the cords over their heads until the popping stopped.
The children's mother, Marilyn Kramer, and Toby's father, William Brewer, were both charged in connection with the fire. Both pleaded guilty to one count of endangering the life or health of a child and were sentenced to five years in the Illinois Department of Corrections.
The inspector general reviews cases where children died despite having come in contact with DCFS in the preceding 12 months.
Overall, there were 123 deaths in the fiscal year that ended last June -- 24 homicides, 37 accidental, 34 natural, seven suicide and 21 undetermined.
It was the highest number since the fiscal year ending in 2005, when there were 139 deaths.
"We, Illinois, must do better," said Meryl Paniak, acting inspector general in the report. "We need to do more to support families early on, before they get into deep trouble. But when families are broken, we need to act decisively to protect children."
Paniak concluded there wasn't a single answer to address the agency's issues, but proposed a set of fixes, including more training, strong supervision of front-line workers and manageable caseloads.
In a timeline of agency involvement with the family after Kramer and Brewer were sentenced to prison last May, DCFS said that it agreed with all 11 recommendations made by the inspector general following an investigation, and it had already adopted many of the recommendations and was working to adopt the remaining.
Though families are not identified in the inspector general annual report, The Herald-Whig confirmed that the review and recommendations involved the fatal fire and previous DCFS contact with the family.
DCFS said the family had an extensive history with the department and had been under investigation by DCFS on nine occasions and had placed the children in foster care for more than two years after police found Kramer asleep on the floor in her home in September 2013 while possessing methamphetamine. All four children were home at the time.
The open case at the time of the fire stemmed from a March 14, 2018, report alleging that Brewer struck Kramer, causing her eye to bleed, and the oldest child was struck with a metal pole while trying to break up the altercation.
The report also alleged that Kramer struck the oldest child with a belt. The report stated that heat and water were turned off at the home and the only heat source were space heaters upstairs.
The inspector general found that six 30-day extensions were granted, resulting in the investigation continuing for seven months.
The investigation was launched after school personnel contacted the DCFS Hotline -- the third time in a year -- after one of the children said he was scared for his sister. The paternal grandmother also told a school counselor that Brewer had a $100 a day methamphetamine habit and that food was limited.
After the children underwent a forensic interview regarding abuse, an investigator reported that they visited the home, but Kramer and Brewer would not let them in but spoke with her outside. Emma was seen eating a sandwich and "looked clean and dressed appropriately." When the investigator asked the parents about methamphetamine use, the parents got upset and went back into the house.
The investigator returned two months later to complete a closing safety assessment and again was not allowed inside by Kramer and Brewer but they again spoke to her outside where Kramer said she did not have identification needed for a drug test.
The investigator later talked to the two oldest children at the schools, and her case notes noted no concerns or observed drug use. However, supervisory notes and an inspector general interview with the investigator confirmed that one of the children said that his parents had an argument and Brewer "jumped on" Kramer and they described items in the home that resembled drug paraphernalia.
The supervisor's notes showed that the child said that "it is worse now" than when they first returned home from foster care because "the parents argue all the time and it is scary."
"Subsequently, over a five-month period, the investigator was directed by her supervisor to prepare a petition to order the parents to comply with services," the report said. "This petition was not filed with the court by the investigator until after the death of the two youngest children."
Five months after the investigation started, Kramer called the investigator to report that she and the children were moving in with the maternal grandmother as she and Brewer were not getting along. The grandmother was never contacted nor did the investigator go to that home to verify the information.
And despite multiple hotline reports of the parents' suspected drug use and history of drug use, the investigator did not have the parents complete drug testing until six months into the investigation in which Kramer tested positive for methamphetamine and amphetamines.
In an interview with the investigator, she stated the closed drug screening place for the agency was about 45 minutes away.
Inspector general investigators also learned that Kramer was involved in a 12-step program and her sponsor was the step-daughter of the investigator assigned to the investigation, which was not disclosed as a possible conflict of interest to the area administrator.
The inspector general recommended that all area staff in the region be retrained on appropriate responses when parents refuse to allow entry into a home, as well as retraining on adequate completion and use of assessments and retraining with the DCFS Office of Legal Services on several topics including conflicts of interest.
It also recommended that the agency should consider sending all child protection teams to the Child Welfare Training Academy to be retrained, including on how to access a family home and completing required assessments accurately and in a timely manner.
DCFS accepted the recommendations and said there was mandatory training with its field office staff.
The inspector general also recommended that an investigation pending more than 60 days should be reviewed to ensure contacts have occurred in a timely manner and the children are safe and that assessments are properly completed, and proper supervision is occuring. Extensions should only be approved if warranted.
DCFS also was directed to complete a review of its drug testing process in the region to make sure resources are readily available.
The agency agreed with the recommendations.
The inspector general also recommended that the area administrator and child protection supervisor be disciplined because of their lack of attention and follow-up when supervising child protection investigators. The investigator now works for the Illinois Department of Human Services, and it recommended that the report be shared with the DHS secretary and other appropriate supervisory staff, as disciplinary action may not be an option.
DCFS said it suspended both the area administrator and supervisor for seven days and that a report was shared with DHS.
The Associated Press contributed to this report.