The state’s Department of Human Services repeatedly violated a policy mandating detailed reports when children die from suspected abuse or neglect, a requirement that experts say is needed to provide transparency, force accountability and prevent future tragedies.

The Baltimore Banner discovered the problem after filing a public records request for reports of all suspicious child deaths that occurred over a five-year period. The reports are known as Form 1080s. Officials denied the request in part because it would have been “unduly burdensome” to fulfill. Only after facing the threat of litigation did the state concede that many of the documents did not exist.

Reports were missing for roughly a third of the children who died in 2023 and 2024, according to data provided by the human services agency. The number of required records missing for prior years is unknown.

Maryland is now working to address the lapse, said Ben Shnider, a spokesperson for the agency. He emphasized that the problem predates Gov. Wes Moore, who was elected in 2022.

“Electronic recordkeeping was extremely deficient before this administration took office,” Shnider said.

Experts said they were stunned to learn that Maryland had not been properly documenting children’s suspicious deaths.

“This is evidence of either corruption or incompetence,” said Emily Putnam-Hornstein, a professor at the University of North Carolina’s School of Social Work. She helps lead a national project focused on preventing child maltreatment fatalities.

The state’s admission is the latest sign of the department’s failure to properly track the deaths of many Maryland children. The Banner revealed earlier this year that officials weren’t sure how many children had died from abuse or neglect. Eventually, the state released revised data showing a lower number than originally reported, but such deaths have still doubled in the last decade.

Although some information on these cases is compiled in an internal database, the mandated reports were designed as a tool for tracking and learning. There are sections such as “briefly describe recommendations for policy change” and “local lessons learned from a review of actions taken before and after the incident.” The 15-page forms must be fully filled out within 60 days of a child’s death, according to a 2022 agency policy the state updated on Oct. 1. The new version maintains the same deadline.

Disregarding the policy may mean missing chances to save another child’s life, experts say.

Shnider could not say how many required Form 1080s exist for suspected child maltreatment fatalities over a five-year period because agency records are disorganized and counting them requires a time-intensive manual review. But state officials noticed the problem of missing records at least two years ago, when they started developing technology meant to ensure reports are generated for every case.

Shnider said the fix, set to go live this fall, is estimated to cost $210,000. Maryland spent $31.9 million overall to design, develop and implement the database it is now upgrading.

“When we took office in January 2023, we found that our recordkeeping and data management fell far short of the standards Maryland families deserve and undermined our commitment to transparency,” Shnider said. The state’s local social services departments are partly responsible, he added. The agency recently ordered them to write any reports required over the last two years that had been missing.

Meanwhile, evidence of Maryland’s struggle to safeguard children is piling up. Last month, a teen in foster care was found dead in the Baltimore hotel room where she had been living. The week before she died, state auditors revealed that Maryland had failed to provide timely medical and dental care to some foster children and placed others in homes with registered sex offenders.

Moore last week vowed to fix problems with Maryland’s foster care system.

“It’s unimaginable that anyone could have any level of confidence in the safety of children in this state,” said Sarah Font, a Washington University in St. Louis researcher who works with Putnam-Hornstein on the Lives Cut Short project.

State Sen. Shelly Hettleman, who cochairs the General Assembly’s joint audit committee, said she was dismayed that the state had failed “the most vulnerable among us.” She called on lawmakers to work together to address the human services department’s persistent problems.

“There doesn’t seem to be any due diligence,” said Hettleman, a Democrat from Baltimore County. “We need to investigate these deaths now. We need to learn from them and ensure they never happen again.”

Unacceptable gap

Reports written by caseworkers following children’s deaths are the foundation of child fatality review, a process required in Maryland under state and federal law. They allow state officials to look for patterns and develop plans to mitigate the deadly trends they discover.

For example, Zai’Lynn Anderson of Howard County and Bryce Wilson of Baltimore County, both infants, died three months apart in 2021. Both babies suffocated while their caregivers were on drugs — one had taken methadone, the other had taken methamphetamine. Both sets of caregivers had also previously been investigated for allegedly abusing or neglecting a child.

Could the agency have done more after the first baby’s death that might have helped protect the second baby’s life? Form 1080s are supposed to help caseworkers study this question. The agency says reports exist for these children, but it won’t share them or reveal what they say.

Shnider said Form 1080s cannot be disclosed because they are part of the case file. The Banner disagrees and is still pushing for disclosure of these records in accordance with a state statute that spells out categories of information that must be shared upon request so long as it would not jeopardize an investigation or prosecution.

State policy requires Maryland’s local departments of social services to start gathering information and documenting it in Form 1080s immediately after a child’s death from suspected abuse or neglect.

Within four days, caseworkers are supposed to record basic facts like the date and location of an incident and check yes, no, or unknown for questions like: Was the child ever placed outside the home? Was the child born substance-exposed? Was the child injured in the 72 hours before the fatal incident?

Within 30 days, the medical examiner’s preliminary findings and an update on the status of the investigation are due. And within 60 days, a final draft of the report must be filed, including a section titled “prevention information.” The records must be dated, approved by a supervisor and sent to the state Social Services Administration, a division of the human services agency.

Since Oct. 1, the state has required local departments of social services to submit the completed reports to certain email distribution lists.

Hundreds of these reports should have been written in recent years. Shnider, the agency spokesperson, placed much of the blame for Maryland’s deficient tracking of children’s deaths on the local departments, even though they are subsidiaries of the state agency.

“Each of the 24 local departments had distinct practices for producing and tracking these forms, if they were produced at all,” Shnider said. “Policies on timelines for filling out forms were inconsistently applied across jurisdictions.”

He added that the agency’s subsidiaries get notified when they violate policy or protocol, and said staff can be reprimanded or even fired as a result. He would not say whether anyone had been disciplined for failing to properly track children’s deaths.

Form 1080s were missing for 68 children who died from suspected abuse or neglect in 2023 and 2024, according to data provided by the human services agency.

Shnider said Maryland’s trouble tracking these deaths dates back decades.

Asked to comment on that claim, Michael Ricci, who was director of communications under former Gov. Larry Hogan, said he hopes the human services agency is as focused on solutions as it has been on attempting to deflect blame. Former Gov. Martin O’Malley said his team conducted robust child fatality reviews and theorized that the practice may have been deprioritized by Hogan, who advocated for shrinking state government.

Caseworkers also fill out a Form 1080 when a death reported to the department gets quickly screened out, meaning no child abuse or neglect is suspected. Shnider said nearly one-third of these reports for deaths that occurred in 2023 and 2024 were also missing. He added that some Form 1080s exist for earlier years but said he did not know how many and whether they correspond to child deaths where abuse or neglect was suspected.

“The gap in recordkeeping we found is unacceptable, and we are moving urgently to ensure all local departments follow the same rules and provide accurate and timely information on child fatalities,” Shnider said.

Long deficient

A 1080 is not the only form caseworkers must complete when a child dies and abuse or neglect is suspected.

State policy also requires caseworkers to complete a report known as a Form 2037 soon after a suspected child maltreatment fatality. These reports are designed to distill key facts about those deaths and convey the information to the public. The department must share the information upon request unless disclosure would prejudice an investigation or prosecution.

The Banner filed a public records request in mid-January, seeking reports corresponding to deaths from child abuse or neglect that occurred over a five-year period. A majority of the Form 2037s given to The Banner were dated in February, indicating they were not written during the required time frame.

“There doesn’t seem to be any due diligence. We need to investigate these deaths now. We need to learn from them and ensure they never happen again.”

State Sen. Shelly Hettleman

When The Banner asked why, Shnider acknowledged that the agency had completed only a quarter of the Form 2037s required for deaths over the last five years before receiving the records request. Most of the reports provided were written by staff in response to The Banner’s Jan. 13 request before they were released this summer, he added.

Some reports were written several years after they should have been created.

For example, Royce Johnson, 2, died in July 2022 from a blood infection he developed after being burned in a scalding bath. The year before, Royce’s caregivers had taken him to the hospital with several fractures they could not explain.

Although medical records revealed a history of prior injuries and a lack of medical care since the boy was 2 weeks old, the broken bones weren’t considered evidence of abuse because investigators could not determine the cause.

A copy of Royce’s Form 2037 provided to The Banner is dated nearly three years after his death.

Shnider said the centralized tracking of these reports has long been deficient. He added that the Moore administration is committed to improving it while holding itself accountable when policies surrounding the production of records are not followed.

A new policy set to take effect in January will require the reports to be written within 30 days of a child’s death from abuse or neglect.

Still, some of the Form 2037s obtained by The Banner are incomplete. Roughly one-third of them note that medical examiner reports for those abused or neglected children were “not received.”

Judith Schagrin, a former assistant director of the Baltimore County Department of Social Services, said these records represent more than just paperwork. They’re supposed to help staff learn how to prevent abuse and neglect.

“There are wonderful, hardworking and diligent caseworkers doing their best to care for the children and keep them safe,” she said. “What we need are the leaders, systems, policies and resources that support their good work.”

Not following the rule requiring timely completion of the forms also increases the chance that key information is mistakenly left out when they do get written.

Tale of 3 reports

Records generated following the death of 4-year-old Malachi Lawson illustrate a pattern of inconsistent recordkeeping. Successive versions of the same report, all prepared years later than required, paint different pictures of what happened.

Malachi’s parents must have known he needed medical help after they burned him during bath time in 2019. They reported seeing the 4-year-old’s skin floating in the tub, Baltimore Police wrote in charging documents.

They said they didn’t take Malachi to a doctor because they feared losing custody of him like they had twice before.

When the boy died, his mother took a Lyft to dispose of his body, according to charging documents. Then she reported him missing, sparking a citywide search. His remains were later discovered in a dumpster across town, and his parents were charged with his death.

In Baltimore, news coverage of Malachi’s disappearance and death was wall-to-wall.

Although some states release child maltreatment fatality records to the public immediately after a death, Maryland requires state’s attorney’s offices to first review public records requests to ensure disclosure won’t jeopardize an investigation or prosecution.

The requirement results in delayed transparency. Four years passed before each of Malachi’s parents pleaded guilty to child abuse resulting in death and the state approved the release of records.

The Banner has received three different versions of his Form 2037.

The first copy, obtained in January 2024, includes a four-page attachment that documents how vulnerable Malachi was from birth and the many chances the child welfare system had to help him. It lacks a clear date indicating when it was created. The report describes how Malachi’s parents were first investigated for alleged physical abuse when he was 2 months old.

The baby had a swollen knee and a broken leg his parents couldn’t explain.

As a result, Malachi was placed in foster care for nearly a year. Then a judge ordered him returned to his mother’s custody over the objections of Baltimore caseworkers. Six months later, he was allegedly assaulted again. He was now about 20 months old.

“Johns Hopkins physician noted numerous injuries to the child and labeled the injuries as suspicious for abuse,” the attachment states. “Johns Hopkins also questioned if the child had received regular medical care.”

Malachi was placed back in foster care, but he didn’t stay very long. By summer 2016, a judge again — despite caseworkers’ concerns — ordered the boy returned to his mother’s custody.

Three years later, he would be dead.

The second copy of Malachi’s Form 2037 obtained by The Banner — dated February 2025 — includes no attachment and few of these details.

It doesn’t state explicitly that he had twice been in foster care, or that caseworkers and judges disagreed about how best to protect him. Although a checked box indicates he had at one point been declared a child in need of assistance, there is no mention of the broken leg he suffered as a newborn or the other injuries he endured as a toddler.

“There are wonderful, hardworking and diligent caseworkers doing their best to care for the children and keep them safe. What we need are the leaders, systems, policies and resources that support their good work.”

Judith Schagrin, a former assistant director of the Baltimore County Department of Social Services

It goes on to say that a report from the medical examiner was never received, and a section asking caseworkers to describe the circumstances of the alleged child abuse or neglect “if consistent with the public interest” is left blank.

A third copy of Malachi’s Form 2037 was shared with The Banner in August.

Although the report’s date did not change, revisions were made that address some of the key facts left off the second copy. And a two-page attachment was added that covers some of the information described in the original detailed attachment.

Shnider, the agency spokesperson, said the state updates and revises Form 2037s and Form 1080s as new information becomes available. But the second and third versions of the report detailing Malachi’s death contained less information than the first.

Shnider said the agency elected to provide “additional transparency” when it shared Malachi’s Form 2037 the first time.

‘Culture of safety’

The state’s struggles could threaten some of Maryland’s federal funding if the government determines the state has failed to abide by child abuse disclosure requirements.

For the last half century, the federal government has provided funding to states that prevent, assess, investigate, prosecute and treat child abuse and neglect. Maryland received $29 million for this purpose and the provision of other social services in federal fiscal year 2024.

One way the state complies with the federal law is by regularly submitting data on child abuse and neglect to the federal Administration for Children and Families, which publishes an annual report. Another way is through the work of the Maryland State Child Fatality Review Team.

Created in 1999 by the General Assembly, the 25-member team includes two pediatricians and officials from multiple state agencies, including representatives from the offices of the attorney general, the chief medical examiner and the superintendent of schools, among others. The governor also appoints 11 members who are to be experts in child safety and welfare.

The team’s mission is to prevent child deaths by studying the causes of prior tragedies and advising lawmakers about potential policy solutions that might save a child’s life. Maryland counties also have local teams with similar mandates.

“The team envisions the elimination of preventable child fatalities,” the group wrote in its most recent report, dated June 30, 2025.

But that report analyzes deaths that occurred four years ago, and the information used to generate it appears to be incomplete. The human services agency has reported there were 54 deaths from abuse or neglect in Maryland in 2021. The report only documents 19 of them. The team has issued no other reports addressing child fatalities that occurred in the years since that time.

It’s unclear where the breakdown in information sharing might have occurred and why the group seemingly isn’t reviewing children’s deaths in a timely manner.

One possible explanation involves miscommunication between Maryland’s State Child Fatality Review Team and its local teams, which are the first to review children’s sudden or unexpected deaths. Amanda Hils, a spokesperson for the state Department of Health, which oversees the state team, explained how the process is supposed to work.

When a child dies, the Office of the Chief Medical Examiner notifies the local review team in the county where the death occurred. Those teams collect and analyze information from a variety of sources, and when abuse or neglect is suspected, they should be reading Forms 1080 and 2037, Hils said. Without the reports, some suspicious deaths may be going unnoticed.

Another possible explanation involves a child fatality database used by the state team that is managed not by the state Department of Human Services, but by local public health coordinators. These officials may be using a different, narrower definition of suspected abuse or neglect than the one used by the human services agency, Hils said.

Richard Lichenstein, who leads the state team, did not respond to a request for comment. He is a pediatric emergency doctor and a University of Maryland School of Medicine adjunct professor.

Shnider said the state is moving with urgency to prevent children’s deaths and support families. He noted that many maltreatment fatalities involve unsafe sleep, and he emphasized that the agency has worked to prevent these deaths. He added that Maryland last year rejoined the National Partnership for Child Safety, a consortium of three dozen states and jurisdictions working together to study past cases, improve decision-making and avoid future tragedies.

“The death of a child is an utterly devastating event for a family,” Shnider said. “The well-being of Maryland’s children is our highest priority.”

Several years ago, the human services agency under Hogan created an “initial plan” to develop a streamlined process for reviewing deaths from suspected child abuse or neglect. The goal was prevention.

“The reviews will reinforce organizational values and shift the focus away from discussions of blame-worthy acts toward creating and supporting a culture of safety,” the plan states.

So often, when a child suffers a tragic death, there is intense focus on the caseworker who was assigned to the victim’s family and not enough focus on systemic problems, like the worker’s caseload, training or level of experience.

This plan promoted a new approach.

It also called for an automated system capable of tracking and documenting all child fatalities and details like age, gender and race. But to make that possible, officials would first need to create Form 1080s for every dead child.

Maryland never did.

Banner reporter Pamela Wood contributed to this report.