Cover Up: The Life and Death of an Oregon Son
Seventeen-year-old J.D. died by suicide after spending more than a decade in foster care and the last 18 months of his life in a series of hotel rooms and short-term rentals.
Our investigative report, “Cover Up: The Life and Death of an Oregon Son,” tells the story of J.D.’s last week in state custody and sheds light on numerous systemic missteps by the Oregon Department of Human Services (DHS) that failed to stop J.D.’s preventable—and foreseeable—death.
Key findings
State law requires the Oregon Department of Human Services (DHS) to conduct a review of any death of a child in its custody. DHS produced the Critical Incident Review Team—or CIRT investigation—on J.D.’s death in August 2024. Although some of the elements of DHS’s CIRT report were truthful, DRO’s investigation found vital elements missing, concealed, or in contradiction:
DHS covered up a major mistake: leaving a rope within reach of a seriously ill, actively suicidal teenager for days after the young man indicated a specific intent to use it to end his life.
The rope was kept in an unlocked closet in the hotel suite—not in a “secure” location, as DHS’s CIRT report claims.
No one interviewed for the DHS CIRT report said the rope was secured in any meaningful sense or provided any reasonable explanation of why it remained in the same hotel suite where J.D. was staying.
DHS’s CIRT report is explicitly false in describing the departure of J.D. from the hotel room.
DHS artificially inflates the sense that staff were alert and aware of J.D.’s actions in a way that is disputed in DHS’s own incident report.
DHS policy requires both staff members to remain awake on overnight shifts when the child is not sleeping. J.D.’s regular trips outside of his room on the night of August 3, 2024, clearly showed he was not asleep, yet only one poorly trained DHS staff member—who had his back to the suite’s front door and both bedroom doors—was awake when J.D. fled the hotel room with the rope.
DHS failed to provide adequate staff training for supervising a suicidal youth who experiences hallucinations.
DHS’s chaotic lack of leadership channels caused no one to take charge—or to accept blame—for J.D.’s foreseeable and preventable death.
DHS failed to find any setting that could care for J.D., meet his needs, and help him deal with more than a decade of trauma and maltreatment.
DHS’s report provided no appropriate fixes and or planning for future potential instruments of self-harm.
Recommendations
Sending abused and neglected children out of state for treatment should be exceedingly rare due to the risk of maltreatment. Similarly, placing abused and neglected children into hotels or other temporary lodging in Oregon should be exceedingly rare because these are not homelike settings, and there is lack of stability in the adult care providers. In both of these settings, the need for a strong regulatory framework and oversight is vital to prevent the further traumatization of children.
Disability Rights Oregon’s investigation found several DHS missteps led to the department’s failure to prevent J.D.’s death. There are clear steps Oregon legislators and DHS should take to ensure another child under DHS’s care does not experience the same failures in the future including:
The Oregon Legislature should:
Fully fund agency requested budgets related to abuse and neglect investigations of DHS, Oregon Youth Authority, Department of Public Education, and Office of Developmental Disability Services.
Amend the statute to require CIRT Reviews be performed by an independent agency that is isolated from the political influence of State Agency heads and executive branch leadership.
Amend the statute to require OTIS Investigations be performed by an independent agency that is isolated from the political influence of State Agency heads and executive branch leadership.
Invest additional funds to develop therapeutic foster care placement, treatment foster care placements, and other intensive mental health services to serve children where they live instead of depending on congregate care settings and hotel rooms.
Set a statutory deadline for the eradication of temporary lodging in hotels and other short-term rentals.
Increase rate reimbursements for therapeutic foster care placement, treatment foster care placements, and other intensive mental health services.
Increase representation of youth, family members, education advocates, foster care advocates, special education advocates, disability advocates, and dependency attorneys on the System of Care Advisory Council.
Amend the statute to require the Department of Human Services to follow Indian Child Welfare Act and create a private right of action against the State, Department of Human Services, and the Director of Child Welfare for any violations of this law.
Oregon Department of Human Services should:
Recruit, develop and fund therapeutic foster care placement, treatment foster care placements, and other intensive mental health services to serve children where they live instead of depending on congregate care settings and hotel rooms.
Develop an emergency plan to eradicate the use of hotels and other temporary lodging and publish the timeline, steps, and plan for the elimination of this practice.
Hire a cohort of DHS staff who exclusively care for children in hotels and other temporary lodging instead of relying on volunteers who work overtime from the child welfare and self-sufficiency teams to staff these placements. This cohort should be provided intensive specialized training and supervision appropriate to supervising vulnerable children in these settings.
Develop and publish trainings, standards, policies, and procedures for the care of children in hotels and other temporary lodging, including supervision of children and youth in psychiatric crisis.
Develop and publish clear decision-making processes for when children and youth will be placed into a hotel or other temporary lodging until such practice is eradicated.
Develop and publish procedures for a single system to share information about the condition and wellbeing of children and youth in hotels and other temporary lodging so that all staff are fully informed of the support plan until temporary lodging is eradicated.
Revisit all DHS training related to children in foster care to create meaningful trauma-informed training, hold all DHS personnel accountable for trauma-informed practices, and take disciplinary action against DHS personnel who traumatize children and youth.
Train all DHS staff on the powers of dependency attorneys, procedures for resolving disputes with dependency attorneys, and legal processes for seeking necessary care and treatment through the court.
Develop a more timely and specific policy and protocol for investigating a child’s death while in custody of the Department.
Follow the Indian Child Welfare Act to respect Tribal Sovereignty.