TEXAS DEPARTMENT OF FAMILY AND PROTECTIVE SERVICES

COMMISSIONER
John J. Specia, Jr.

A Review of Department of Family and Protective Services Involvement

Child Fatality
Over the course of six years, Child Protective Services (CPS) received fifteen reports and
conducted nine investigations into allegations that Ryan Welch or his siblings had been abused
or neglected. The majority of those investigations remained incident driven and either failed to
delve into underlying issues in the home, or failed to provide recommended services to the
family. While CPS was in the process of seeking legal intervention to address both immediate
and ongoing concerns, Ryan died from a gunshot wound. This report describes the major issues
found during the review of Ryan's death and actions that CPS is taking to address those issues.
During the review of a child fatality, certain areas of improvement may be identified including
individual training needs, statewide trainings, policy revisions, updates to best practice
guidance, and/or revisions to state statutes.
Several of the historic issues noted in investigations involving Ryan's family are contributing to
revisions of CPS practice and policy as part of CPS Transformation. For example:
A program specialist has been hired to provide additional support to field domestic
violence concerns. Other efforts currently underway will address domestic violence in
investigations and service delivery including enhancements to training, guidance on
dispositions and utilization of services to address family dynamics, intimate partner
violence, and impact of trauma on the family.
Risk assessments and structured decision-making tools are being implemented. The
safety assessment tool will assist a caseworker during the first contact with a child and
family, a critical opportunity to assess safety. The new risk assessment tool will be more
objective and based on actuarial principles that have been scientifically accepted and
adapted for Texas.
The case transfer process between Investigations and FBSS staff is being simplified and
expedited. That fluid transition begins once an investigator identifies that a family can
benefit from ongoing services.
The Child Safety Review Committee, a standing workgroup of external and internal
stakeholders to CPS, has identified the need for ongoing training and resources to staff
surrounding firearm safety guidelines and working with families to address child safety
when firearms are in the home or may be accessible to children.
An audit of the Child Safety Specialists is currently underway to strengthen these subject
matter experts' roles in addressing child safety. Child Safety Specialists are legislatively
mandated positions designed to assist regional staff in assessing and addressing risk
and safety for children. The Child Safety Specialist provides feedback on case related
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issues involving policies and practice standards to enhance service delivery, especially
on high-risk cases when families have had multiple referrals to DFPS and also must
approve certain investigations prior to closure. This includes approving investigations
involving child fatalities or when an investigation has a disposition of reason to believe,
unable to determine, or unable to locate and involves a child under the age of four where
no services will be provided to the family at case closure.
Summary of CPS History on Ryan Welch / Family of Ryan Welch
Intake #1: December 2, 2009 - February 1, 2010 / Completed Investigation
o Intake #2: December 19, 2009 - December 22, 2009 (addressed in Intake #1)
o Intake #3: December 30, 2009 - December 31, 2009 (addressed in Intake #1)
Intake #4: March 1, 2011 - May 19, 2011 / Completed Investigation
Intake #5: June 14, 2011 - July 16, 2011 / Completed Investigation
Intake #6: September 12, 2011 - December 19, 2011 / Completed Investigation
Intake #7: April 15, 2013 - May 10, 2013 / Completed Investigation
Intake #8: July 13, 2013 - August 5, 2013 / Completed Investigation
Intake #9: August 27, 2013 - November 20, 2013 / Completed Investigation
Intake #10: May 19, 2014 - June 19, 2014 / Completed Investigation
o Intake #11: May 20, 2014 - May 21, 2014 (addressed in Intake #10)
Intake #12: October 25, 2014 (currently open) / Open Investigation
o Intake #13: Nov. 8, 2014 - Nov. 10, 2014 (addressed in Intake #12)
o Intake #14: Nov. 20, 2014 - Nov. 21, 2014 (addressed in Intake #12)
o Intake #15: Nov. 20, 2014 - Nov. 20, 2014 (addressed in Intake #12)
On December 2, 2009, Ryan's parents were investigated for neglectful supervision, physical
abuse and physical neglect of Ryan's oldest brother. Allegations included a lack of food in the
home, no utilities, and ongoing domestic violence. There were concerns that the child was
malnourished and below size for his age. Allegations also included that the parents were leaving
the child with a relative whose disabilities prevented him from caring for the child. Two additional
intakes were received during the investigation alleging that there were no heat/utilities in the
home and that the home had significant health and safety hazards such as roaches, rodents
and cat excrement throughout the home.
The investigator followed up with law enforcement. There were no records of domestic violence
calls involving either parent or child. These allegations were ruled out because the home had
working utilities and parents denied domestic violence. The investigation closed in February
2010.
OCS Assessment:
While the investigation was initiated within 72 hours as a Priority II investigation,
attempted and actual contact with the family was not made within required time frames.
CPS Policy 2348. Follow-Up When Contact Is Not Made Within Priority Time Frames
requires that an action plan must be developed and include attempts to contact the child
no less than once every 72 hours until the case is formally staffed for closure as Unable
to Locate. The mother was contacted by phone 19 days after the intake and the child
was not seen face-to-face until January 17, 2010, 46 days after the intake.
The investigator received information about the child's primary care physician and
immunization status, but there was no documented follow-up with this provider.
Concerns about the child's weight were not addressed in the investigation.
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The physical neglect allegations were ruled out although the concerns were not
addressed in the investigation.

On March 1, 2011, Ryan's parents were investigated for physical abuse of the children based
on concerns surrounding domestic violence between the parents while the children were
present. There were additional concerns regarding the children's access to drugs when at their
father's home. Both parents admitted to having arguments with the children present but denied
physical aggression. The children had no visible injuries during the investigation. The home
condition was clean and orderly. The investigator made contacts with professional collaterals to
check on any concerns with the parents or children; no concerns were noted with the care of the
children, no concerns of substance abuse, and reports that both parents were appropriate with
the children. The allegations were ruled out and the investigation closed in May 2011.
OCS Assessment:
The investigation was not initiated timely and actual contact with the family was not until
May 2011. CPS Policy 2253. Time Frames for Initiating Priority I and Priority II
Investigations requires a Priority II investigation to be initiated with 72 hours.
The safety assessment was not completed until May 2011.CPS Policy 2311.2. Time
Frames Related to the Initial Safety Assessment requires that the safety assessment be
completed within the first seven days after the investigation is initiated.
While the father had completed anger management classes just prior to the
investigation, the reported altercation occurred after completing this service. This repeat
incident after services had been completed suggests that additional interventions or
services were necessary to address the domestic violence occurring in the home.
An incident of domestic violence had been reported but then downplayed by the family.
The difference in the explanations between the original domestic violence incident and
then the follow-up discussion show a minimization of the concerns and safety threats
present in the home.
The concerns of substance abuse were not fully explored, as there was no drug test
completed.

On June 14, 2011, a new intake was received alleging neglectful supervision as Ryan's sibling
was able to get out of the home early in the morning and get into the front seat of a car without
an adult present. Additionally, there were allegations of physical abuse regarding the domestic
violence previously investigated. The allegations of neglectful supervision and physical abuse
were ruled out as the child was able to get out of the home but the parent followed outside after
him. The parents safety proofed the home so that the child could not get outside again on his
own. The investigator contacted professional collaterals to confirm the welfare of the children
and check on any concerns regarding the family. Parents completed drug tests and were
negative. The investigation was ruled out and closed in July 2011.
OCS Assessment:
The allegations surrounding domestic violence were not explored with the mother.
On September 12, 2011, an investigation was launched after allegations of medical neglect,
neglectful supervision and physical abuse were received. Allegations included that the mother
hit Ryan's sibling daily and grabbed the child by the hair; there were concerns that Ryan was
supposed to wear a special cast for his clubfoot but that the parents did not make him wear the
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cast; and it was alleged that the parents leave the children with a family member who suffers
from medical conditions that render him unable to care for the children. During the investigation,
it was noted that home environment appeared somewhat unstable as the parents continually
separated and reunited, moving frequently between homes of their own and that of their
relatives. The investigator noted that while the parents denied any domestic violence, others
have reported witnessing the altercations and case history suggests that there is domestic
violence occurring. During the investigation, the worker contacted professionals to discuss
concerns regarding the family. There were no concerns regarding the health of Ryan and
domestic violence concerns had been addressed through anger management for the father. The
investigation was ruled out and closed in December 2011.
OCS Assessment:
The investigation was not initiated within 72 hours as required in a Priority II investigation
and actual contact with the family was not until 36 days after the intake. CPS Policy
2253. Time Frames for Initiating Priority I and Priority II Investigations requires a Priority
II investigation to be initiated with 72 hours. CPS Policy 2348. Follow-Up When Contact
Is Not Made Within Priority Time Frames requires that an action plan must be developed
and include attempts to contact the child no less than once every 72 hours until the case
is formally staffed for closure as Unable to Locate.
The safety assessment was not completed until December 2011. CPS Policy 2311.2.
Time Frames Related to the Initial Safety Assessment requires that the safety
assessment be completed within the first seven days after the investigation is initiated.
Allegations of physical abuse were never fully assessed. While the children did not have
outward signs of injury, the parents never directly discuss the physical abuse allegations.
The investigator did identify that counseling may be of help to the family and provided
them with a resource for counseling. However, there was no follow-up to verify that the
family was in counseling.
While the Child Safety Specialist completed a Multiple Referral report and provided
specific guidance to staff such as referring the family to Family Based Safety Services
(FBSS), completing a more thorough interview with the father, having the parents
complete psychological evaluations, and providing parenting and counseling services to
the family, the investigator did not refer the family to FBSS.
On April 15, 2013, an investigation was launched due to allegations of physical abuse as Ryan
had scratches all over his face that did not have an explanation. Ryan was developmentally
delayed and had a speech delay/autism spectrum disorder. The parents stated that the
scratches came from Ryan and another child fighting over a toy at school the previous day. The
scratches were photographed and appeared superficial/not in need of medical treatment. The
investigator followed up with professionals to inquire about the children's medical care and to
discuss any concerns. None were noted. All children were seen and there were no signs of
abuse or neglect. The allegations were found unable to determine for an unknown perpetrator
as the scratches appeared to be superficial and it was unknown as to when or where the
scratches were received. The investigation was closed in May 2013.

OCS Assessment:
During a routine discussion with the parents about home safety, there was a
conversation regarding firearms. The investigator did not fully assess the safety and
storage of the firearms away from the children.
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On July 13, 2013, Ryan and his family were residing with extended family members. Concerns
about the home condition included roach infestation and animal feces in the home as four pets
were kept inside. There were concerns that a sibling had cradle cap and marks from scratching
her head. Two investigations were launched -- one with Adult Protective Services and one with
Child Protective Services. During the Adult Protective Services investigation, there was
evidence of roaches throughout the home, animal feces in several rooms, and food for the
various pets throughout the home. The CPS investigator completed a parental child safety plan
with the family so that the children would be out of the home until the home was cleaned and
the dogs were placed in a secure area away from the children. In this case, it is noted that there
are concerns that the father has guns in the home and concerns about domestic violence in
general, although the parents deny this. The parents had cleaned the home, mopped and
steamed floors, had the pets removed from the home and provided a receipt for an exterminator
who completed a follow-up treatment a week later. During a subsequent visit, the animals were
not in the home and the home condition had improved. The CPS investigation was ruled out
allegations of physical neglect and closed in August 2013 as the home condition had been
addressed and no other concerns for abuse or neglect were noted.
OCS Assessment:
There are concerns about firearms in the home but the investigator does not fully assess
the safety and storing of the firearms away from the children.
The investigator made contact with the family and observed the home in unsanitary
condition. Based on the condition of the home, the investigator should have contacted
the supervisor at the time of the visit to discuss further case directive. A Parental Child
Safety Placement was not sought until the following day, after concerns were shared
with the supervisor. In CPS Policy 2433. Making the Parental Child Safety Placement, a
caseworker must have supervisor approval for the Parental Child Safety Placement.
There were no services offered to the family during this investigation although. Services
may have been helpful, such as a psycho-social evaluation, counseling,
homemaker/parenting services, domestic violence screening and service referrals, and
ongoing Family Based Safety Services.
On August 27, 2013, a new intake was received for physical neglect and medical neglect,
alleging that the home conditions had deteriorated again and that the children all had poor
personal hygiene. Ryan was alleged to have a gash on his head that was alleged to be infected.
There was also concern that the youngest child had whooping cough. During the investigation,
the home was noted to be clean and free of hazards. Ryan did have a cut on his head from
being hit by a toy thrown by another child. The parent was treating the injury but the child picked
at the scab. The investigator contacted professional collaterals to ensure that the children's
medical and educational needs were being addressed. The mother had a sibling tested for
learning disabilities and ADHD during the investigation. The case was staffed with the county
attorney's office as the parents refused to cooperate with the investigation and refused drug
testing. The allegations were ruled out and the investigation closed in November 2013.
OCS Assessment:
While the investigation was initiated within 24 hours in a Priority I investigation,
attempted and actual contact with the family was not made within required time frames.
CPS Policy 2348. Follow-Up When Contact Is Not Made Within Priority Time Frames
requires that if caseworkers are unable to make actual contact within 24 hours of a
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Priority I report, they must attempt to make contact every calendar day until contact is
made with each alleged victim; a protective parent; a principal; or a collateral with new
and relevant information. The mother and children were on September 10, 2013, 14
days after the intake.
While the Child Safety Specialist completed a Multiple Referral report and provided
specific guidance to staff such as completing unannounced visits, assessing firearm
safety in the home, assessing the medical care for the children and referring the family
for FBSS service, these referrals were not completed and the family did not receive
FBSS services.
The investigator staffed the case with Legal as soon as the family became
uncooperative to assess the ability to have legal intervention to drug test the parents or
cooperate with the ongoing investigation; however, legal intervention was denied by the
county attorney's office.

On May 19, 2014, there were concerns of physical abuse reported as Ryan had a number of
scratches and bruises all over his body including to his arms, knees, and scratches to his
nose/head. It was reported that he was constantly dirty, wore soiled clothing and had body odor.
It was alleged that these conditions had persisted since August 2013. Additionally, the child's
backpack smelled of marijuana previously. The investigator originally needed law enforcement
assistance to see the children as the mother refused any contact. Ryan continued to wear a
brace to address his clubfoot. The injury to Ryan's head was allegedly from playing with toys
with one of the other children and did not appear to need medical attention. The investigator
followed up with law enforcement that had no reports to the home. In addition, contacts were
made with medical professionals who had no concerns and had recently seen the children. The
investigation was ruled out for physical abuse and closed in June 2014.
OCS Assessment:
The investigator did not initiate the investigation until May 26, 2014, seven days after the
intake was received. The investigation was not initiated within 72 hours as required in a
Priority II investigation and actual contact with the family was not until 36 days after the
intake. CPS Policy 2253. Time Frames for Initiating Priority I and Priority II Investigations
requires a Priority II investigation to be initiated with 72 hours. CPS Policy 2348. FollowUp When Contact Is Not Made Within Priority Time Frames requires that an action plan
must be developed and include attempts to contact the child no less than once every 72
hours until the case is formally staffed for closure as Unable to Locate.
Conflicting information from law enforcement on the scene was given: the officer knew
the family from patrolling the area but also stated that there were no callouts to the
family home.
The school was not contacted to assess the ongoing needs of the children or any
concerns that the school may have had.
On October 25, 2014, an intake was received stating that the family was again living in poor
conditions with animals/animal feces throughout the home. In a bedroom of a family member,
there was trash surrounding the bed with roaches and flies on the walls. The mother and
children reside at the home of a relative while the father lives at another location. When the
investigator went to the home to interview the family, the mother would not allow the worker into
the home and law enforcement assistance was requested. The father and officer arrived at the
home and assisted the worker in seeing the children outside. While Ryan had scratches on his
face, they did not appear to need medical attention. The parents explained that the scratches
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were from playing outside. The parents were fighting for custody of the children and the mother
had pulled Ryan from school so that the father would not be able to take him from school. The
mother stated that the police had been out to the home previously but would not discuss why.
The mother refused the investigator's request to enter the home and would only allow her to do
so the following day. When the investigator arrived at the home the following day, the mother
again refused entry to the home and refused to speak to the caseworker.
On November 4, 2014, an affidavit was filed with the court to aid in the investigation and
seek a motion to participate in services. The hearing was scheduled by the court for
November 18, 2014 to which the parents and their attorney did not attend. The hearing
was rescheduled for December 2, 2014.
Additional intakes were received on November 8, 2014 alleging unsanitary living
conditions, and two intakes on November 20, 2014 alleging that Ryan had several
scratches and peck marks to his face and neck. The investigator returned to the home
on November 21, 2014 to meet with the mother and see Ryan to assess the latest
allegations. Again, the mother would not allow the investigator into the home but did
allow Ryan to go outside. The mother stated that the new scratches were from a sibling.
The father filed a family violence report on or around November 22, 2014, due to the
mother hitting him while he was trying to pick up a child for visitation. The mother alleges
that she is the one who was hit.
On November 25, 2014, Ryan died from a gunshot wound. The mother had left the
children unsupervised for three hours that morning while she was outside. The home
conditions were deplorable with a foul stench, animal feces/urine throughout the home,
and covered with flies and roaches. Several safety hazards were noted including broken
glass, trash, cockroach nests, no functioning plumbing in two used restrooms, and open
access to a firearm, an air rifle, and a machete. During the investigation into Ryan's
death, domestic violence was confirmed between the parents and had been occurring
since at least 2010.
On December 2, 2014, the court hearing was held and the surviving siblings were
brought into the conservatorship of DFPS. At the time of the fatality, the home condition
was deplorable with a foul stench, animal feces/urine throughout the home, and covered
with flies and roaches. The surviving siblings were brought into the conservatorship of
the Department of Family and Protective Services.
OCS Assessment:
Because not all parents had been served the required notice through the court system
prior to the hearing, the hearing was reset.

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