Red Flags Ignored: DHS Fails, Boy with Autism Dies Alone
On or about February 1, 2025, a teenager died alone in his Oregon home, where he lived with his mother and her boyfriend. By the time his body was discovered, “Lucas” had been dead 2-3 weeks.
Our investigative report, “Red Flags Ignored: DHS Fails, Boy with Autism Dies Alone,” used sealed documents from the state and interviews to examine the cascade of failures by the Oregon Department of Human Services (DHS) to protect “Lucas” from abuse, neglect, and, ultimately, death. [“Lucas” is a pseudonym. Name and geographic locations were anonymized in the report to protect confidentiality.]
Key findings
The investigation reconstructs a harrowing timeline: a sudden and unexplained withdrawal from school in November 2024; three increasingly alarming abuse reports filed within weeks; and troubling observations by school officials and law enforcement of dire conditions at home.
DRO’s investigation found several DHS systemic errors failed to stop Lucas’s tragic and preventable death:
DHS arbitrarily screened out urgent abuse and neglect reports.
Although three different reports were received in just seven days, DHS inexplicably screened out the first two. The third took seven weeks to investigate in violation of established timelines. Allegations in the reports included Lucas was removed from school for no reason, rapidly losing weight, evidently being isolated at home, and being denied food.
Denial of food—well-established by all three complaints—is neglect and counts as abuse under Oregon law.
DHS allowed its investigation to stall and be derailed.
After finally opening an investigation on December 18, 2024, DHS did not report any attempt to contact Lucas between December 21, 2024, and February 12, 2025. Lucas died during that time.
DHS did not investigate whether Lucas was being denied food—or address the loaded rifle pointed at a barricaded front door that school staff had observed when visiting the home.
DHS violated the law regarding Critical Incident Review Team investigations following Lucas’ death.
The statutes creating the Critical Incident Review Team (CIRT) process explicitly prohibit the participation of local DHS staff to avoid a conflict. However, five local DHS staff participated in the CIRT investigation of Lucas’s death, skewing the self-assessment of DHS’s repeated failures.
The CIRT investigation resembles a work of fiction.
While the CIRT report claims DHS “demonstrated diligence in engaging the family, (and) providing referrals to supportive services,” DHS mostly left passive voicemail and sent text messages.
Recommendations
This investigation and report make clear: Oregon must strengthen its protections for children in care and ensure that the Department of Human Services is following the law. While no recommendation can undo Lucas’ tragic death, the following recommendations for DHS and legislators are offered in DRO’s investigative report.
The Oregon Legislature should:
Amend the statute to require follow-up reporting on implementation of CIRT recommendations, available on a public dashboard.
Amend the statute to require CIRT Reviews be conducted by an agency that is isolated from the political influence of State Agency heads and executive branch leadership.
Not weaken the substantiation standard for investigations of abuse and neglect. More children, people with disabilities, and older adults will be hurt while DHS intervenes in fewer cases.
Strengthen and clarify Oregon’s definitions of threatened harm and neglect so DHS screeners appropriately screen-in cases of abuse, neglect, and threatened harm.
Prevent any cuts to budgets related to abuse and neglect investigations of DHS, Oregon Youth Authority, Department of Education, and Office of Developmental Disability Services.
Cease all DHS authority expansion or discretion over the placement of children in their custody until the systemic failings in this report—and in Disability Rights Oregon’s 2025 investigative report—are addressed.
Oregon Department of Human Services should:
Revise and clarify its criteria for opening Child Protective Services investigations. In Lucas’s case, DHS rejected two abuse reports before accepting a third despite materially similar information. When reports are ambiguous, DHS should follow up with reporters to clarify concerns.
Abandon passive child welfare practices that rely on waiting for parental engagement. Child welfare practice must be child-centered and include regular, direct contact with the child.
Require safety planning whenever credible safety threats are identified. Instead of developing a safety plan that could have saved Lucas’s life, DHS settled for leaving voicemails encouraging his mother to seek services.
Ensure referral to its Office of Developmental Disabilities Services when it has an open child welfare case involving a child with a known intellectual or developmental disability.
Make the CIRT process a meaningful driver of continued agency improvement—not a public relations exercise to cover up DHS’s failings.
Comply with Oregon law prohibiting staff directly involved in a case from participating in CIRT reviews while routinely including responsible outside participants to restore credibility.
