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State Department of Human Services investigations into two recent child fatalities revealed multiple missteps by York County's Office of Children, Youth and Families.

One case involved the death of 3-year-old Kelly Williams, fatally shot in April in her Manchester Township home by her father, who also shot his mother and himself in an apparent murder-suicide pact, according to police.

Northern York County Regional Police said Frankie Thomas Williams, 21, and his mother, 50-year-old Tammy June Williams, made the murder-suicide pact together, and he carried it out.

Investigators determined the double murder-suicide was in response to Kelly's mother filing for full custody of the girl, according to Lt. David Lash.

More: Police: 3 dead, including tot, in Manchester Twp. murder-suicide

The Department of Human Services' report, finalized Sept. 22, states the county child welfare agency was alerted in February to alleged drug use by Frankie and Tammy Williams and a troubling history between Frankie Williams and Kelly's mother that included domestic abuse and threats to kill her if she left with Kelly.

The report shows that York CYF staff visited the home Feb. 3 and closed the investigation less than two weeks later — determining that the child was safe — despite not interviewing Kelly, failing to conduct a full walk-through of the home and not following up after Kelly's mother and Frankie and Tammy Williams all refused to take drug tests.

The department also notes that Kelly's mother left the York County home in the midst of the agency's investigation to live with her parents in North Carolina, but no follow-up interview was conducted with her.

"The ... investigation appeared to be superficial even though the allegations and the history provided by the referral source were very concerning," the report states.

Another death: A second department report details the April death of a physically disabled 4-year-old girl, whose name The York Dispatch has chosen to withhold because no charges have been filed and she has a living sister and two half-siblings.

York CYF received seven separate referrals involving the girl before her death, including one in which her caretaker allegedly masturbated in front of her and her sister in 2015, according to the Oct. 2 report.

Charges of unlawful contact and open lewdness against the caretaker were eventually dropped, though he did voluntarily surrender his nursing license in 2016.

More: Faces of child abuse in York County

More: York caretaker accused of lewd acts surrenders license

Most of the referrals involved allegations of physical violence against the mother by her live-in boyfriend, including one instance in which he allegedly held a gun to her head in front of the girl, the report states.

The mother filed for several Protection from Abuse orders against the boyfriend and was granted an emergency Protection from Abuse Order after police were called for a domestic violence incident on Nov. 11, 2015, according to the report, but he was in the home when York CYF staff visited two days later.

The report notes that the agency did not document any attempt to notify the police of this violation of the Protection from Abuse Order.

"Further, throughout all of the reports of domestic violence received and confirmed, there is no documentation in the record regarding offering information and assistance to the mother regarding domestic violence services that would be available to her," the report states.

In April, after the mother's boyfriend had moved out of the house, the 4-year-old girl was rushed to the hospital after vomiting in the middle of the night and being unable to breathe, according to the report. She was declared dead shortly after arriving, the report notes.

The coroner ruled her death to be of natural causes, though the autopsy showed she had inflamed tonsils and high carbon dioxide levels at the time of her death. During the  investigation, the mother tested positive for THC, but no charges have been filed.

Agency troubles: The department's determinations of non-compliance in these two cases marks the latest area of concern for the embattled York County child welfare agency.

The agency was sued in October for allegedly placing a boy in foster care with a known pedophile, and it had received four consecutive downgraded licenses between 2015 and 2016. One more failed inspection would have resulted in the state department taking over control of day-to-day operations.

More: Lawsuit: York CYF placed boy in foster care with known pedophile

More: Report: Pennsylvania child abuse workers swamped, underpaid

York CYF Director Terry Clark said the department's reports on the two child fatalities have directly led to some changes within his agency.

All caseworkers and supervisors have been required to attend additional training that simulates an in-home visit, which Clark described as "pretty intensive," and the agency's quality assurance staff has been instructed to conduct more frequent case reviews.

In addition to meeting with caseworkers about each case every 10 days, supervisors are being instructed to review each caseworker's notes every 10 days, Clark said.

He said mistakes like the ones noted in the department's report are often the direct result of overwhelmed caseworkers.

A recent report by Auditor General Eugene DePasquale notes that the state's county caseworkers are often overworked, underpaid and inadequately trained.

These factors have led to staff turnover as high as 90 percent in York County during a two-year period, according to the report.

Clark said that the state requires so much documentation that caseworkers often don't have enough time to spend with families and get paperwork done.

"I hope the public is able to recognize that caseworkers are really trying to do their best to protect children," he said.

The agency recently submitted a request to the state for a $59.5 million budget that would include an additional 30 positions as well as salary increases and more employee training.

— Reach David Weissman at dweissman@yorkdispatch.com or on Twitter at @DispatchDavid.

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