Nebraska releases evaluation of suicide prevention measures within CFS

State’s inspector general examined deaths of three young people ages 11-16 who died by suicide while in contact with the DHHS Children and Family Services division
A report from the Nebraska Inspector General's Office says the state's Child and Family Services department needs to do more to address and prevent suicides.
Published: Jul. 25, 2023 at 3:02 PM CDT
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LINCOLN, Neb. (WOWT) - The state of Nebraska said Tuesday that it had investigated three deaths by suicide by youth whose families were in contact with the state’s Children and Family Services division.

The inspector general’s office found the actions of CFS and those working with families did not contribute to and were not responsible for the deaths in these particular cases, which occurred between December 2018 and December 2022.

What it did find, however, was that CFS does not have a comprehensive and standardized approach to suicide prevention and lacks consistent training, policy, and procedure to address the issue.

Among the recommendations the OIG laid out in its findings:

  • CFS needs to create a comprehensive suicide prevention plan with input from the Nebraska State Suicide Prevention Coalition
  • Appropriate training should be provided for all CFS employees and foster parents.
  • Required training should also be part of contracts with private providers of foster care support services.

Inspector General Jennifer Carter said the increased risk for suicidal youth involved with the child welfare system showed an increased need for response to the problem by CFS.

According to the report summary: “While adolescents in general are at an increased risk of death by suicide, youth involved with the child welfare system are impacted at an even higher level than when compared to their peers. Youth involved in the child welfare system report higher rates of suicidal ideation and self-harm behaviors.”

Carter also noted that Nebraska DHHS accepted the recommendations laid out by the OIG and has committed to implementing a comprehensive plan for suicide prevention measures in place by the end of 2025.

DHHS sent along this statement in response to the report:

“In its letter dated June 27, 2023, the Department of Health and Human Services (DHHS) accepted all six recommendations made by the OIG. DHHS has already finished a workplan to complete the recommendations and is beginning the implementation process. Improving mental health services for Nebraska’s youth is a top priority. If anyone, including youth is experiencing suicidal ideation or a family member or friend has concerns for a loved one, please call, chat, or text 988. The 988 suicide hotline provides a direct connection to trained, compassionate, accessible care, and support for anyone experiencing suicidal ideation, substance use, and/or a mental health-related crisis. 988 is available 24/7 and is a free service available to anyone in need of support.

In addition, DHHS is continuing work to expand mental health services for Nebraskans of all ages throughout the State by implementing Certified Community Behavioral Health Clinics (CCBHCs) and the development of a statewide behavioral health plan. DHHS is working with all three branches of government to develop strategies aimed at transforming child well-being in Nebraska.”


Again, in all three cases, the Office of Inspector General of Nebraska found that the actions of CFS and others working with the families did not contribute to — and were not responsible for — the deaths in these particular cases.

The three incidents the OIG looked into involved boys ages 11-16:

  • An 11-year-old whose parents had been deported a few years earlier died in December 2022. In this case, CFS had completed a safety assessment and provided mental health referral information. While classified as an “open alternative response case,” the child died five days after the boy’s guardian, who was also a relative, declined further services.
  • A 14-year-old who had been a ward of the state for a year after incidents of domestic violence in his home died in December 2018. In this case, CFS had been working with the family to broaden their therapy options, but the family never took steps to get that help. According to the report, CFS had “well over 50 documented contacts with the family.”
  • A 16-year-old who had been sexually abused by a family member and impacted by the death anniversary of a relative, who also died by suicide died in 2021. In this case, CFS became involved in February 2021, three weeks before the boy died while receiving “ongoing services.” Prior to his death, CFS had completed its initial assessment and had arranged in-home referral services; but the boy had not yet been able to meet with that provider.


According to the 2021 Nebraska Youth Risk Behavior Survey, known as NYRBS:

  • 22% of Nebraska high school students reported seriously considering attempting suicide in the past 12 months
  • 18% of high school students, during that same period, made a suicide plan
  • 10% of surveyed students reported attempting suicide at least once in the 12-month period

NEED HELP? If you or someone you know is considering suicide, call or text the National Suicide Prevention Lifeline at 988 to access a trained crisis counselor.

Digital Producer Zane Culjat contributed to this report.