The report was released Thursday. DOI was called upon to see what role ACS played in Jaden Jordan's death last November. The boy died after being severely beaten at his home in the Gravesend section.
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DOI Commissioner Mark Peters found that even though ACS received the report of alleged abuse on Saturday, November 26, investigators did not find the child until he was allegedly beaten into a coma on Monday, November 28.
"If ACS had followed their normal protocols they would have had that address on Saturday and had the ability to find Jaden Jordan two days before he was beaten to death."
The boyfriend of Jordan's mother, 24-year-old Salvatore Lucchesse, has since been charged in the case.
"DOI's investigation found that the depth of errors over a two-day period was so significant, and the errors involved the overall implementation of policies so basic, that they go to the heart of ACS's core mission of protecting children and implicate high-level, systemic problems," the report said.
The report said that ACS indicated to DOI that its own investigation found that none if its staff had improperly handled the case. But ACS has recently informed DOI that it is taking actions against six staff members, retaining and disciplining some - including suspension.
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"ACS's position throughout this investigation has been that any breaches of policy and reasonable case practice are outliers. However, DOI's investigation has confirmed that the vulnerabilities that caused these problems are systemic and require a comprehensive remedy."
The DOI said the most significant issues found were the in the agency's Emergency Children's Services unit, which handles cases during nights, weekends and holidays. The DOI said it found this unit had inadequate staffing, case practice, supervision and training.
Here are DOI's specific findings about the ECS unit:
- ECS managers were inconsistent on reviewing newly disseminated policies with their employees.
- ECS staff could not recall the last time they received training.
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- ECS supervisors reported they do not have time to review the work of Child Protective Specialists ("CPS") to see if essential case work is thoroughly completed.
- Due to high caseloads, CPSs within ECS reported that before going out in the field they cannot wait for various database searches to be completed, such as criminal background and domestic incident checks.
For Jaden Jordan's death, DOI said had the allegations against the boy come in during normal business hours, the case would have gone through trained specialists.
The DOI has now issued a series of recommendations to ACS, including reporting all allegations of ongoing criminal conduct to the NYPD immediately.