Quality Assurance Review

Child Victim: Chance Walsh

Date of Death: October 15, 2015 (Date Chance was Found Deceased)
County: Sarasota
FSFN Report: 2015-265514
DCF Region: Suncoast
County of Residence: Sarasota
County of Occurrence: Sarasota
Judicial Circuit: 12
Date of QA Review: October 23, 2015
I. Introduction
On October 4, 2015, the Florida Department of Children and Families received a report concerning a 9-week-old
infant, Chance Walsh, who had not been seen by relatives for approximately three weeks. At the time the
report was received, Chances parents were in South Carolina and were providing both family and law
enforcement officials with conflicting stories regarding the babys whereabouts. Chances body was later found
buried in a remote area of North Port, Florida (Sarasota County) on October 15, 2015, after a tip was received by
the Sarasota County Sheriffs Office. Following the discovery, the parents (32-year-old Kristen Bury and 36-yearold Joseph Walsh) were extradited back to Florida where they are being held on murder and child neglect
charges in connection to the death of their infant son.
According to court documents, Chance allegedly died on September 16, 2015, after he was repeatedly struck by
Mr. Walsh. The infants body was then left in his crib before it was wrapped in a blanket and placed in the closet
of the home. When the smell of decomposition became overwhelming, the couple eventually buried their sons
remains in a shallow grave on or about September 24, 2015, after which time they fled the state.
II. Case Participants
Participant Name
Chance Walsh
Kristen Bury
(aka Kristen Walsh and
Kristen Millwater)
Joseph Walsh

Age
9 weeks
(age at disappearance)
32 years

Race
White

Relationship/Role
Decedent

White

Mother

36 years

White

Father

III. Child Welfare Summary

Chance Walsh was born via Caesarean section delivery on July 27, 2015, at Bayfront Health Port Charlotte
(formerly Peace River Regional Medical Center), weighing 6 lbs. 13 oz. Based on the information contained in the
medical records, Chance was in relative good health despite Ms. Burys lack of prenatal care, and both he and his
mother tested negative for all substances at delivery.
The Florida Abuse Hotline was contacted the following day on July 28, 2015, at which time the reporter noted that
Ms. Bury had recently given birth to a baby and that she may be using opiates. The reporter also stated that the
parents had been staying in a hotel because their house burned down and made reference to an infant death that
occurred in 2014 (which was previously investigated and determined to be the result of natural causes). The
reporter narrative further indicated that the reporter had limited information and didnt have first-hand knowledge
of the allegations because of very limited interaction with Ms. Bury. As a result, the counselor made the decision to
screen out the intake believing that it did not rise to the level of reasonable cause to suspect abuse or neglect.

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Chance remained hospitalized for three days following his birth before he was discharged on July 30, 2015. Within
three days, Chance was brought back to the hospital at which time he was diagnosed with jaundice. He was
released the same day on August 3, 2015, with no additional concerns noted.
Two months later, the Department received the aforementioned report concerning Chances unknown
whereabouts.
Aside from the screened out intake and the current investigation, there were no other calls to the hotline regarding
Chance and his parents. Both Ms. Bury and Mr. Walsh, however, have respective child welfare histories
independent of one another, as well as one report involving them as parents of another child.
Regarding the mother, Kristen Bury:
Between 2002 and 2003, there were two reports involving Ms. Bury (aka Ms. Millwater)

Regarding the father, Joseph Walsh:

Between 2003 and 2008, there were seven reports involving Mr. Walsh that occurred during the course of a
previous relationship.

Regarding Ms. Bury and Mr. Walsh as a couple:

In April 2014, a report was received regarding the death of 1-month-old
who was found
unresponsive after sleeping in bed with his mother (Ms. Bury) and father (Mr. Walsh). The death was subsequently
determined to have been the result of natural causes stemming from a sudden and severe kidney infection.
Although cooperative with law enforcement officials, the parents refused to be interviewed by child welfare
investigators, citing all of the information could be obtained from the North Port Police Department. Given the
medical examiners findings, the investigation was subsequently closed with no findings of maltreatment and no
on-going services were warranted given that the couple had no other children.
IV. System of Care Review
This section is designed to provide an assessment of the child welfare systems interactions with the family prior to
the childs death and to identify issues that may have influenced the systems response and the quality of decisionmaking. A review of the parents prior child welfare history was conducted and it was determined that the level of
intervention and subsequent actions taken by the Department were appropriate. Because the prior history involves
other children whose identities are protected by confidentiality laws, specific details cannot be released. For the
purpose of this review, the primary focus will be in regards to the opportunity for the Departments intervention
following Chances birth.
A. Practice Assessment
The Florida Abuse Hotline serves as the central reporting center for allegations of abuse, neglect, and/or
exploitation for all children in Florida. The Hotline receives calls, faxes, and web based reports from citizens
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and professionals with concerns of abuse, neglect, or exploitation on children. When a reporter contacts the
Hotline, counselors ask a series of questions regarding the callers initial concern, the severity of the situation,
any history related to the situation as well as questions regarding the family dynamics. The series of
questions asked by the counselors are to determine if the information statutorily meets criteria to accept an
abuse or neglect report. The Hotline Counselor also obtains demographic information and a means to locate
on the subjects of concern. With this information the counselor conducts a search to determine if the family
has prior history to assist with making the final determination. These searches are done in real time during
the duration of the call. Criminal history information is not available to hotline counselors and is obtained by
the technical unit and sent out to the field after the report has been accepted.
There are several different systems routinely utilized by a counselor: the first system that is searched is FSFN
to determine if there is any child welfare history for any named child, parent or other participant. The
Department of Health Vital Statistics portal is used to enhance or obtain additional demographic
information. For example, you may have an accurate date of birth for a child provided by the school system,
but no information regarding the parents. The Vital Statistics portal can aid in the ability to accurately identify
the mother or father through the birth certificate record. Counselors can also use the agencys data base for
food assistance and Medicaid Recipients (Florida ACCESS), as well as the Florida Licensing and Motor Vehicles
database for address searches. Once a search is complete, a counselor also has, in addition to supervisory
support, reference tools that include the Child and Adult Maltreatment Index to help identify whether a call
meets the criteria for an investigation and also to accurately establish a maltreatment type.
The following findings were noted:
Hotline
The information documented in the written narrative of the screened out intake conflicted with
the information that was shared during the recorded call to the hotline and did not include
significant statements made by the reporter.
The written narrative of the screened out intake indicated that the reporter had no first-hand
knowledge due to limited contact with Ms. Bury. During the call, however, the reporter
indicated that the two were acquaintances and that they had interactions over the past two
years.
While the written narrative of the screened out intake noted that the parents had been
staying in a hotel due to their house burning down, it did not reflect the reason noted by the
reporter as being the result of them operating a meth lab.
The call made to the Florida Abuse Hotline on July 28, 2015, which was subsequently screened
out, should have been accepted for investigation with the maltreatment codes of Substance
Misuse, Environmental Hazards, and Threatened Harm.
Substance Misuse Although the reporter implied that the majority of the allegations were
hearsay, information obtained suggested that Ms. Bury was a long-time drug user who was
using an opiate inhibitor.
Environmental Hazards While the narrative noted the parents were residing in a hotel due
to their house burning down, in the recorded call made to the hotline, the reporter indicated
that the house burned down as a result of a meth lab explosion.
Threatened Harm Based on the parents prior histories, there was reason to suspect another
child would be at risk in their care.
Reporting
While the initial call to the hotline was screened out, there were several additional opportunities
in which a call to the Florida Abuse Hotline was warranted, however, no additional calls were
received.
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 While the screening at the hospital was not completed due to no opportunity to talk
privately with Ms. Bury, the information that was obtained and documented in the hospital
records noted several items that should have raised a red flag with regards to Ms. Burys
ability to properly care for her newborn child. These items include:

After the report was received concerning Chances unknown whereabouts, relatives disclosed
on-going concerns that were known early on and witnessed consistently. These concerns,
however, were never previously reported to the Florida Abuse Hotline. They include:
On-going and chronic substance use by both parents the parents had reportedly
been on a drug binge for months.
Domestic violence in the home the mother was recently observed with a black eye.
B. Organizational Assessment
Hotline
The Florida Abuse Hotline has designated personnel who conduct ongoing quality assurance activities at the
hotline. A review of the circumstances surrounding this case revealed no systemic issue at the Hotline as
protocols were in place to assist the counselor in the assessment of information and subsequent decisionmaking. On September 1, 2015, the Florida Abuse Hotline, in partnership with the Office of Child Welfare,
deployed a new Quality Assurance initiative through Windows into Practice: Guidelines for Quality Assurance
Reviews. Prior to that time, the Hotlines continuous quality improvement process involved review of a
portion of screened out intakes and call monitoring by the reviewer who then provided feedback to counselor
supervisors.
The Hotline completes daily qualitative reviews in child and adult screened in and screened out intakes.
During the month of September 2015, the Hotline screened out a total of 5,637 child related intakes, of which
Hotline quality assurance completed secondary reviews on 1,516 (27%) screened out intakes. Of the screen
out reviews completed, only 12 (0.8%) were found to have been incorrectly screened out. When the
determination is made that the intakes were initially screened out incorrectly, the Hotline then screens in a
new intake to address the allegations. The Hotline also receives feedback from program administrators,
supervisors and investigators on an ongoing basis. Field staff are empowered to call the Hotline to request
reconsideration of screen in decisions. During the month of September, the Hotline screened in a total of
19,636 child-related intake reports. Of those intakes sent out to the field for investigation, field staff called
back 260 (1.3%) intakes for reconsideration of a screening decision. Of those fewer than half (.065%) were
deemed not to meet the criteria for an investigation. In April 2014, Action for Child Protection, Inc.
(contracted experts) completed a report following a review and observation of practice and protocols that
were in place at the Hotline, and concluded that both the screening decision and response priority assigned to
the referrals was supported in all of the calls that were observed.
In addition to the Hotlines on-going qualitative initiatives, the following findings were noted:
Training and Resources
The hotline counselor received a Bachelors Degree in Criminal Justice in 2014 before beginning
employment with the Department in June 2014. The level of training and amount of resources
provided were appropriate preparation for the position and was inclusive of the following:
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 In September, following the initial training period, the counselor went through a nesting
period, where brand new counselors have 100 percent of their calls reviewed before calls are
disconnected and reports read before submission to the field. The nesting period typically
lasts for one to two months and is individually tailored to each counselors progress.
Following training, counselors receive ongoing guidance from their direct supervisors, other
surrounding call floor supervisors, managers, and specialists who are available for live
consultations.
Counselors also have their desk reference guide as well as access to electronic resources
where they can reference both Chapter 39 and 415 of the Florida Statutes and administrative
code, as well as the Departments operating procedures pertaining to abuse report
acceptance criteria.
Hotline Quality Assurance (Newly Enhanced Practice as of 09/01/15)
The Departments Windows into Practice: Guidelines for Quality Assurance Reviews contains a
very detailed Quality Assurance (QA) process with regards to all programs areas. For the Florida
Abuse Hotline, designated QA staff conducts a variety of on-going activities in an effort to ensure
that practice standards are followed. These include:
Frontline Supervisory Reviews that include a sample of intakes from new employees and
screened out calls, as well as 100 percent of intakes in which there have been three or more
unaccepted reports on a single child. This type of review is conducted on a daily basis and
offers the earliest opportunity for ongoing consultations regarding information and decisionmaking.
Other Types of Reviews
Base Reviews completed by the QA specialists from the Hotline
Side-by-side Reviews completed jointly by the QA specialists from the Hotline and
the Office of Child Welfare
Independent Reviews completed by the QA specialists from the Office of Child
Welfare
Field Feedback Reports that offer an assessment from the field with regards to the decision
and key data elements associated with the intakes.
Case Consultations in which the QA specialist, hotline counselor, and supervisor participate in
a discussion about the sufficiency of information, decision-making, and written report of a
specified intake in which the findings are then entered into a web portal.
Investigations
By the time the report was received in October 2015, Ms. Bury and Mr. Walsh were in another state and baby
Chances whereabouts were unknown. During the course of this investigation, the working relationship
between local law enforcement and child welfare officials was noted to be a significant strength.
Although the active investigation was received following Chances reported disappearance, the
information available in the record supports a very cohesive and collaborative working
relationship between the Departments Child Protective Investigations unit and the Sarasota
County Sheriffs Office. The sheriffs detective assigned to the case worked closely with the child
protective investigator and promptly shared critical information and pertinent details as law
enforcement officials remained diligent in their effort to locate the missing infant.
C. Service Array
Floridas Healthy Start initiative was signed into law on June 4, 1991, and provides for universal risk
screening for all Florida pregnant women and infants per 383.14(2) FS and 64c-7.008(1) FAC. Healthy
Start risk screening is the collection of information on the designated prenatal and infant screening forms
used to assess risk and identify those women and infants most vulnerable of experiencing adverse health
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outcomes. For pregnant women, the adverse outcome is pre-term labor and/or low birth weight, and for
infants the adverse outcome is infant death between 28 and 364 days after birth. Studies that have linked
birth outcomes to Healthy Start infant screening data indicate that infants who score 4 or more on the
Healthy Start screen are six times more likely to experience post neonatal infant mortality than those who
score less than 4.
The range of Healthy Start services available include:
Information, referral and ongoing care coordination and support to assure access to needed
services;
Psychosocial, nutritional, and smoking cessation counseling;
Childbirth, breastfeeding, and substance abuse education;
Home visiting; and
Interconception (period between pregnancies) education and counseling.
The following findings were noted:
In this case, the opportunity to engage the family was problematic.
Because Ms. Bury received no prenatal care, the initial prenatal Healthy Start risk screen could
not be completed.
The general screening conducted at the hospital was not completed due to no opportunity to
talk privately with Ms. Bury.
While Ms. Bury consented to the postnatal Healthy Start risk screen during her hospitalization at
the time of Chances birth, she declined participation in the program and the release of her
screening information. Because Ms. Burys score was less than 4 on the Healthy Start screening
tool, it did not rise to the level to require an automatic referral into the program, and therefore,
no services could be initiated.
There are 32 Healthy Start coalitions and one county health department that provide Healthy Start
services covering all of Floridas 67 counties. The coalitions conduct assessments of community resources
and needs, identify gaps and barriers to effective service delivery, and develop a service delivery plan to
address identified problem areas and issues.
Although Ms. Bury gave birth in a neighboring county, officials with the Healthy Start Coalition in
Sarasota indicated there is a process in place so Healthy Start screenings and/or referrals are
forwarded to the mothers county of residence once the information is received. Had Ms. Bury
been receptive to services, the cross-county referral would have presented no barrier to service
provision. Because she declined to participate in the program, no referral was initiated.
VI. Summary
The Department conducted a review of the screened out intake and determined that while there were
deficiencies in practice, as previously outlined in the Practice Assessment of this report, the identified issues
were not related to any noted systemic issue. Rather, the identified concern was an error in decision-making
made by an individual who did not correctly utilize the existing tools, protocols and supports that are readily
available when determining the criteria for intake acceptance.
In addition to the noted process enhancement and subsequent personnel action in which the counselor was
moved into another position, the Hotline has also instituted the following directive:
If a hotline counselor is making the screening decision to screen out a report, and there is knowledge of a
prior child fatality, the counselor is required to consult a supervisor, who will then document the
consultation within the report, regardless if the report is screened in or screened out.
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