Editor’s note: This story contains discussions of suicide. If you or someone you love is considering self-harm, support is available 24 hours a day at the national suicide crisis lifeline by calling 988.
When a 17-year-old placed in child welfare’s custody died last summer, Oregon officials investigated and issued a report. The goal of such a report is to identify systemic issues and prevent future child harm.
But in the death of Jacob, who was living in state-paid hotel when he died, Oregon’s public accounting was misleading and in some places inaccurate, according to a report released on Thursday by the advocacy group Disability Rights Oregon. OPB is not using Jacob’s last name for this story because his family was not immediately available for comment.
“It’s very clear the (Oregon’s Department of Human Services’) first response is to defend itself and protect itself,” said Tom Stenson, who authored the report digging into Jacob’s death.
Jacob is seen in this undated image provided by his attorney. The 17-year-old had spent years bouncing between residential treatment centers, foster homes and short-term rentals, and died by suicide on Saturday.
Courtesy of Annette Smith
In the 42-page report, titled “Cover Up: The Life and Death of An Oregon Son,” Stenson offers new details into Jacob’s death that he was able to obtain because Disability Rights Oregon is a federally-designated protection and advocacy system for the state. Under that designation, DRO has the ability to access confidential records from agencies that serve people with disabilities.
Disability Rights Oregon’s report only refers to Jacob as “J.D.” in their report, but OPB has previously reported on Jacob’s life and intentionally chose to use his name: members of his family said they felt it humanized a kid whose life was often full of dehumanizing moments.
The latest report is not about one individual or employee at DHS, the disabilities rights’ group notes.
“The numerous problems documented here arose almost entirely because of systemic failures within DHS: Its failures to train its employees, its failure to set standards for employees, its failure to explain clearly the importance of their role, and its failure to appropriately supervise the placement of a vulnerable youth in their care.”
Oregon Department of Human services officials said they are grieving with the family, caregivers and community over Jacob’s death.
“We all share a common struggle of not having the necessary amount of behavioral and mental health care facilities and providers that kids need in crisis. We know children are safest in stable environments that meet their needs, not in stopgap measures like hotel stays and emergency rooms,” said Matt Kinshella, a spokesman for the department.
State officials said they followed state statue and rules to the best of their abilities.
“But we can’t fill the gaps alone; only more, better-equipped care settings can do that,” Kinshella said. “That’s why we are working with our system partners, the governor’s office and legislature to ensure placements and services are developed and made accessible to children and young adults with high needs.”
More to the story
Jacob, like many kids placed in Oregon’s care, bounced around, moving more than 50 times between short-term rentals, residential treatment centers and foster homes. But he spent much of the last two years of his short life living in a hotel in Eugene.
He died by suicide, using a rope he had purchased at a sporting-goods store a week before his death. Staff knew he intended to end his life with the rope, according to DRO’s report. But DHS staff nonetheless placed it in a closet in a hotel suite where the teenager was living. The rope sat in an unlocked closet, inside an unlocked room and Jacob had access, according to DRO’s report. This piece of information is a stark contradiction to the state’s report, which said the rope was “secured in a staff room in the hotel” where Jacob didn’t have access.
“DHS’s misrepresentation covered up a major mistake in the matter: 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 DRO report states.
Around 4 a.m. on the day of his death, Jacob went into his room, got the rope and ran from state caretakers.
The DHS report digging into Jacob’s death says staff made an effort to de-escalate but that Jacob ran anyway. The Disability Rights Oregon report details evidence showing Jacob ran so fast, staff could not do much, not even grabbing their shoes before chasing after him.
More disconcerting is the only awake staff person with Jacob that night was an administrative assistant “who had no relevant training beyond a few hours via an online training program.” This, the report notes, was the backstop appointed for a kid who had openly talked about ending his life repeatedly and who tried to jump off a bridge a few months prior.
DHS left a teenager experiencing an acute psychiatric crisis in a hotel suite with one sleeping staff member and one awake staff member who had almost no relevant training, the report alleges.
“Once J.D. left his hotel room, a concerned staffer chased him, barefoot, for miles,” the report states. “DHS staff did not lack courage nor determination; they lacked the resources, training and leadership they needed to protect J.D.”
The state was responsible for Jacob for the majority of his life. In 2019, Oregon Department of Human Service officials promised in a legal settlement to stop placing kids in hotels recognizing the harm it does and the risks involved. But it didn’t stop. Instead, Oregon spent millions of dollars housing hundreds of kids in hotel rooms.
Leading up to Jacob’s death, DHS staff continued to look for a better placement for him than a hotel.
Staff considered civil commitment for a minor, but determined even if they managed to get a court order to force him to treatment, there was no place to go, according to the DRO report.
One staffer said Jacob’s attorney “wouldn’t allow” Jacob to go to Looking Glass, a placement in Eugene. But the records that Disability Rights Oregon reviewed show DHS withdrew its petition to send J.D. to Looking Glass after it became clear he could not be sent there without his consent.
Lack of responsibility
Everyone agreed Jacob should not have been in a hotel room.
“DHS’s efforts, however, demonstrated substantial passivity and lack of responsibility, in that their initiative largely focused on getting someone else to take care of J.D.,” the report states.
The report contends Oregon officials blamed other people publicly rather than contemplating its own role: from Jacob for not consenting to treatment, to his attorney, the courts and law enforcement.
“Disturbingly, for much of the last year of J.D.’s life, and certainly in the months that followed (his) prior suicide attempt, DHS had no plan for J.D.,” the Disability Rights Oregon report states. “The only plan was for him to remain in the hotel room indefinitely … DHS’s plan appeared to simply be for J.D. to sit in a hotel room until he aged out of foster care on his 18th birthday.”
After the state investigates a child’s death, officials come up with a list of recommendations. The advocacy group’s blistering reporting calls the state’s recommendations a “kitchen-sink full of known bad practices largely irrelevant to J.D.’s life and death.”
The state’s report suggested loosening restrictions on restraints and seclusions and allowing child welfare officials to send kids to facilities in other states when placements couldn’t be found in Oregon. Lawmakers in the ongoing Oregon legislative session are weighing a bill that would support out-of-state placements. It has backing from DHS.
Disability Rights Oregon came up with an alternate list of recommendations that they think will prevent future deaths like Jacob’s. They include:
- Allowing an independent agency to carry out investigations of child deaths so they aren’t influenced by the state agency or the executive branch
- Investing more into therapeutic foster homes and mental health services that serve children where they are at, as well as paying designated therapeutic foster parents more
- Set a statutory deadline for ending the practice of housing children in temporary lodging like hotels
- Having better training for DHS staff and hiring a cohort who exclusively care for children in hotels or other temporary lodging.
This report may be updated.
