Subcommittee reviews audit finding 150 child deaths were not evaluated by MDHHS Office of Family Advocate

The Michigan House Oversight Subcommittee on Child Welfare heard testimony about an Office of Auditor General performance audit, issued April 10, 2025, that found the Michigan Department of Health and Human Services''s Office of Family Advocate (OFA) excluded 150 child death notifications from its Safe Systems review evaluation process and did not complete Safe Systems reviews for a substantial number of deaths that met the review criteria.

The audit, which covered Jan. 1, 2023, through June 30, 2024, concluded OFA's efforts "were sufficient with exceptions," said Ivy Jaroche, audit manager for performance audits of MDHHS at the Office of Auditor General. The report identified a material finding that OFA needed to improve its Safe Systems review process and a second material finding about validation and error correction for MDHHS's publicly reported Child Fatality Registry information.

Why it matters: Safe Systems reviews (SSR) are retrospective, system-focused examinations of child deaths designed to identify systemic barriers and recommend policy or practice changes. The audit said OFA did not consistently evaluate all child death notifications that met SSR criteria, collected inaccurate data for some reviews, and did not always distribute its 2022 Safe Systems Review annual report to all internal MDHHS offices with responsibilities related to the report''a lapse the auditors characterized as a material condition.

What the audit found

- OFA excluded 150 child deaths from its SSR evaluation process during the audit period and did not complete SSRs for a significant portion of…