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CASE FILE E - INTAKE REPORT #2025-04-1922
CASE IDENTIFICATION
Case Number: 2025-04-1922
Intake Date: April 18, 2025
Reporter: Mandated (Emergency Room Physician)
Report Type: Initial Report - PRIORITY
Family System Status: No prior CPS involvement
FAMILY COMPOSITION
Primary Caregiver: Amanda Foster, Age 29, Mother (Biological)
Secondary Caregiver: Kyle Foster, Age 31, Father (Biological)
Child Subject: Lily Foster, Age 6, Female (Kindergarten)
Siblings: None
HOUSEHOLD INFORMATION
Address: 2847 Willow Creek Drive, Riverdale
Housing Type: Owned single-family home, 3-bedroom
Neighborhood: Middle-income residential area
Employment: Mother - Marketing Coordinator (Remote), Full-time
Father - Project Manager (Construction firm), Full-time
Household Income: ~$105,000/year (estimated)
Insurance: Private health insurance through father's employer
PRESENTING CONCERN
Child brought to ER by mother at 11:30 PM on April 17, 2025. Presenting complaint: "Lily fell down the stairs." ER physician (Dr. Hassan) noted multiple injuries of varying ages:
CURRENT INJURIES:
- Spiral fracture of right forearm (X-ray confirmed)
- Bruising on right ribcage (approximately 5 inches across, deep purple)
- Swelling and tenderness in right shoulder
- Abrasion on forehead (fresh, consistent with recent fall)
OLDER INJURIES:
- Healing bruise on left shin (yellow-green, approximately 7-10 days old)
- Small circular scar on left forearm (approximately 1 cm diameter, healed, consistent with burn)
- Faint bruising on upper back (fading, approximately 10-14 days old)
Dr. Hassan noted injury pattern "highly concerning for non-accidental trauma." Spiral fracture mechanism inconsistent with simple fall down stairs. Multiple injuries of different ages suggest pattern rather than single incident. Consulted with pediatric trauma specialist who agreed with assessment.
When interviewed by social worker in ER, Lily was quiet and gave brief answers. Initially stated she "fell down stairs" but when asked specifically about arm injury, became silent and looked at mother. Mother became defensive when questioned about older injuries, stating "she's a clumsy kid" and "I don't appreciate the accusations."
COLLATERAL INFORMATION
- School (Maplewood Elementary) contacted: Teacher reports Lily has been increasingly withdrawn over past 6 weeks
- Teacher noted she has seemed "scared to answer questions in class" recently (change from previous confident behavior)
- One notation in school file from 3 weeks ago: "Lily seemed uncomfortable during PE, said her shoulder hurt, when asked said she 'bumped into door'"
- School attendance: 92% (decline from 98% in first semester)
- No previous concerns reported to school administration
- Neighbors report family "keeps to themselves," no concerns previously noted
INITIAL SAFETY ASSESSMENT
Protective Factors:
- Adequate housing and financial resources
- Both parents employed
- Child has access to medical care (though delayed seeking care for some injuries)
- No prior CPS history
- Child enrolled in school
Risk Factors:
- MULTIPLE INJURIES OF VARYING AGES - strongly suggests pattern of abuse
- Spiral fracture highly concerning for inflicted trauma
- Explanation inconsistent with injury mechanism
- Delay in seeking care (injuries occurred at home, did not seek immediate care until late evening)
- Mother defensive and uncooperative with ER staff
- Possible circular burn scar (concerning for inflicted injury)
- Child appeared fearful and inhibited in presence of mother
- Recent behavioral changes noted by school (withdrawal, fear)
- Declining school attendance coinciding with behavioral changes
IMMEDIATE ACTIONS TAKEN
- EMERGENCY SAFETY PLAN IMPLEMENTED: Child admitted to hospital for medical treatment and protective custody pending investigation
- Law enforcement notified (mandatory for suspected physical abuse with serious injury)
- Court petition filed for Emergency Protective Custody
- Scheduled forensic interview: April 19, 2025 (within 24 hours)
- Medical exam: Completed in ER, full skeletal survey ordered to check for additional fractures
- Collateral contacts: School contacted, pediatrician will be contacted
- Both parents present in ER, interviewed separately by police and CPS worker
PRELIMINARY RISK INDICATORS
- Evidence of current harm: HIGH (multiple injuries including fracture, pattern of varying ages, mechanism inconsistent with explanation)
- Caregiver capacity: SERIOUS CONCERNS (defensive behavior, inconsistent explanation, possible pattern of inflicted injuries)
- Home environment stability: Appears stable outwardly (adequate housing, employment) but home safety is HIGHLY QUESTIONABLE given injury pattern
- Child vulnerability: HIGH (age 6, multiple injuries, behavioral changes suggesting trauma, appears fearful)
- Family support systems: Unknown (family isolates, no extended family mentioned)
CASE NOTES
***PRIORITY CASE - HIGH RISK***
This is a first-time report, but the severity and pattern of injuries is extremely concerning and consistent with ongoing physical abuse. The presence of multiple injuries at different stages of healing is a red flag for repeated non-accidental trauma. Spiral fracture of the forearm, particularly in a child this age, is highly suspicious for abuse (typically occurs from forceful twisting).
The family presents as stable and functional on surface (middle-income, employed, homeowners, no prior CPS history), which may have allowed pattern of abuse to go undetected. Teacher's recent concerns about child's withdrawal and the shoulder pain complaint from 3 weeks ago suggest possible escalation or that abuse has been ongoing but unreported.
Mother's defensive posture in ER and child's inhibited behavior in mother's presence raise serious concerns. The circular scar on child's arm, if confirmed to be a burn, would add another dimension of concern regarding type and pattern of abuse.
IMMEDIATE PRIORITIES:
1. Child safety secured through protective custody
2. Complete medical evaluation (skeletal survey critical to identify any additional fractures)
3. Forensic interview to obtain child's account in safe environment
4. Law enforcement investigation concurrent with CPS investigation
5. Assessment of both parents separately
6. Comprehensive evaluation of injury pattern by child abuse pediatrician
This case requires intensive investigation and likely court intervention. The severity of injuries and pattern strongly suggest this child is at high risk for serious harm if returned to home without comprehensive safety assessment and intervention.
Assigned Worker: Sarah Chen, MSW (Priority Assignment)
Supervisor: Michael Rodriguez, LCSW
Law Enforcement Contact: Detective Maria Santos, Special Victims Unit
Next Review Date: DAILY until custody hearing (scheduled April 20, 2025)
Court Hearing: Emergency Protective Custody Hearing - April 20, 2025, 9:00 AM
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