In 2025, 16 children who had contact with a child welfare agency in Nevada died mostly because of abuse or neglect, while another 39 children experienced a near-fatal incident for the same reasons. The culprit, officials say, are gaps in documentation and follow-through as well as a system stretched thin.

State officials and representatives from county welfare agencies have used the words "devastating" and "horrific" to describe the findings of a legislative report on the matter at an interim legislative committee hearing on Aug. 27. 

But they argue that the solution is not necessarily new laws. Rather, they point to factors such as staffing shortages, high turnover and a lack of resources that often leave caseworkers struggling to navigate complex and difficult situations with little support.

"Every child fatality is a tragedy or near-fatality is a tragedy," Pamela Mann, director of the Washoe County Human Services Agency, told lawmakers. "Each carries with it a responsibility to examine our work and learn from what occurred and then use what we learn to make meaningful changes." 

The report outlined areas of concern that included:

• Inadequate oversight of placement and supervision of children to control safety threats. 
• Poorly performed safety assessments. 
• Reviews that ignored or undervalued evidence.
• Insufficient information gathering to assess caregiver protective capabilities and other dangers.
• Not following guidelines. 
• Improperly screening reports of abuse or neglect at intake.

The findings come as scrutiny of the Division of Child and Family Services (DCFS) and county welfare agencies has intensified in recent months. Almost 100 people filed a lawsuit in June alleging widespread physical and sexual abuse in Nevada's juvenile detention facilities, and a report found welfare and safety concerns in about a third of children's facilities reviewed by state officials.

Report raises concerns, officials point to improvements

The most recent report stems from a bill passed in 2007 that requires child welfare agencies to submit case files of children who suffer a fatality or near-fatality if the agencies had prior contact with the child or family. The legislative auditor is then required to review information and determine if any measures or changes could have helped prevent the fatality or near-fatality.

In total, reviewers analyzed 148 such cases and found in 55 of them that abuse or neglect was a primary factor. Some of those cases may include preexisting health issues and other situations outside the control of caseworkers or other officials.

The state oversees child welfare in counties that have fewer than 100,000 people, which are every county except for Clark and Washoe. Those two most populous counties oversee residents within them.

Jessica Keith, the child welfare deputy administrator for the Division of Child and Family Services, told The Nevada Independent that, statewide, officials have seen an overall improvement in the number of fatalities and near-fatalities that require public disclosure in the last three years. 

As of June of this year, she noted that 31 cases have been disclosed, and if disclosures continued at this rate for the rest of the year, there is potentially a 32 percent reduction, though disclosure rates vary each quarter.

"We are seeing things get better. There are always things that we're working on to make changes," she said. "The safety of children is always our first priority, and we are working to improve our data, improve our transparency, comply with federal and state requirements, and we have dedicated professionals that are signing up for a very hard job that has very intense conditions."

Caseworkers: High turnover and emotional tolls

In discussions with state lawmakers, agency officials attributed some of the problems outlined in the report to high staff turnover stemming in part from the emotional toll of the work, a lack of longevity in the workforce and a shortage of workers. 

Caseworkers, Keith and others noted, are not just people with clipboards. She said they are first responders on the front lines who are often working in intense conditions with families who are experiencing extreme stress and trauma. Most people, Keith said, do not want a job where they go into someone's home and say that there were reports of potential child abuse and must navigate human crisis and complex family systems.

State law caps the ratio at 30 kids per caseworker, but officials noted that the smaller the children-to-caseworker ratio, the better. Fewer caseloads, Keith said, allow caseworkers to spend more quality time with kids and better assess circumstances.

Officials also cited difficulties ensuring everyone is properly trained, pointing out that while there's specialized training for new caseworkers and staff, it's the minimum information needed to do the job. The judgment required in child welfare develops over time, they said, explaining why strong supervision, ongoing training, manageable workloads, experienced co-workers and access to community resources are so important.

Keith said it can take several years on the job to develop an in-depth understanding of what risk looks like and how best to address it.

"We're always adding trainings. DCFS continually conducts additional assessments of staff needs, but then there's still that piece where you just have to get the practice under your belt," she said.

Officials with Washoe County noted that it takes about three years for a child welfare caseworker to become fully proficient because so much of the judgment required in the work develops through experience.

Ryan Gustafson, the assistant county manager in Washoe County, said it's "pretty rare" to have caseworkers with more than five years' experience because many shift into supervisory roles as staff moves through the agency over time. 

Resources: 'Our options are limited'

In a follow-up conversation with The Nevada Independent, Gustafson said that the county receives about 6,500 reports of abuse and neglect every year that require review to determine whether the information meets criteria for further assessment or investigation. Of those roughly 6,500 reports, he said between 1,300 and 1,900 are assigned to an assessment worker for investigation, which can take weeks or months. 

"Workers are often making decisions while information is incomplete, evolving and sometimes conflicting," he said. "Our challenge is less about the capacity to receive reports and more about supporting the complex work that begins once a case is assigned."

He noted that the rate of children being removed from their families' homes in Washoe County has decreased in recent years, which he said reflects a greater emphasis on prevention, clinical services and other evidence-based practices. Notably, he said rates of fatalities or near-fatalities among people who have had contact with their child welfare agency have slightly decreased in recent years in Washoe County even as more children are able to remain with their families.

Nevada is last in the nation when it comes to mental healthcare for children, he said, adding that abuse and neglect are wrapped up in that. For continued reduction of deaths and near-deaths from abuse or neglect, he said there's a need for broader improvements in resources and familial support as well as increased numbers of caseworkers.

The county, he noted, took over the children's mobile crisis response services, bringing response rates to more than 93 percent, and they will open a behavioral health center in 2027, but it still needs more funding and resources.

Capacity matters as much as policy, he pointed out. Officials can strengthen policies, training, assessments and communications, Gustafson said, but those improvements must be matched by resources for children and families, including prevention and in-home services, respite, behavioral health treatment and crisis care.

"A caseworker can identify exactly what a child or family needs, but if the service, provider, treatment bed, or appropriate placement isn't available, our options become limited," he said.

Kimberly Abbott, administrator of the Division of Child and Family Services, said that across the state, many caseworkers are newer and relatively inexperienced. In Nevada's 15 rural counties, the issues are compounded by a lack of available workforce. 

New laws or better support?

Though state lawmakers asked whether there were statutory frameworks that could improve outcomes for children, Abbott said she didn't have specific suggestions, later noting that there are local multidisciplinary teams that review these cases and then report up through a statewide executive committee on child death reviews. The committee aims to recommend future policy changes to improve outcomes.

Keith separately told The Nevada Independent that additional statutory changes may not be necessary because officials have to be careful not to intervene in a home without legal cause.

She also pointed out there are non-statutory ways to improve outcomes. For example, a 2022 review showed increased fatalities or near-fatalities related to opioids. State officials made recommendations to hospitals to include screening questions about new mothers' opioid use, and opioid-related baby deaths subsequently dropped.

From a legislative perspective, she said additional funding could better support more prevention programs and other efforts.

In several instances, state reviewers wrote in the report that they issued letters to child welfare agencies expressing concerns about how the cases were handled. They noted that agency officials conducted internal reviews and identified the need for additional improvements, including clarifying and reinforcing policy and practice, improving documentation and providing staff training.

Abbott said the state has taken steps to identify areas in Nevada where there are problems and to provide support to ensure policies are being followed and caseworkers are properly trained.

"We believe that we have responded to the audit committee's concerns, and we will continue to monitor compliance and reinforce those expectations," Abbott said. "I know our county child welfare agencies have undertaken similar improvement activities."