In 2021, emergency room social workers at Mary Bridge Children’s Hospital in Tacoma called Child Protective Services 11 times asking for assistance. 

Each time, a child had been left in the ER — abandoned, as far as the hospital was concerned — by their parent or guardian.

And each time, when asked to help find the child someone to care for them, the agency said no. 

The experience at Mary Bridge is an example of what hospital staff describe as a new and concerning trend across the state’s pediatric emergency rooms. Medical staff at all three of Washington’s children’s hospitals say they’re increasingly keeping children who are not in need of long-term medical or psychiatric care in the ER for days or weeks because there’s nowhere else for them to go.

The phenomena represents an atypical form of “boarding,” a term that refers to a person living in limbo inside a hospital unit that’s ill-suited to their needs. A more common type of boarding involves patients in psychiatric crisis, like 16-year-old Dylan Tonseth, who has several mental health conditions and lived in the Sacred Heart Children’s ER in Spokane for 33 days. Children in need of intense therapy or long-term residential stays are increasingly finding themselves stuck in ERs without access to an inpatient bed — a problem that existed pre-pandemic but is only getting worse

Housed at the Hospital

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The 11 cases at Mary Bridge, though, represent a different problem from what Dylan experienced, hospital workers say. Most of the children came in with behavioral or psychological concerns, but were stabilized by hospital staff and ready to be discharged. But they couldn’t leave. Their parents or guardians refused to pick them up. In prior years, the hospital could rely on Child Protective Services, or CPS, to take an abandoned child into custody, but the agency no longer does this, state officials and hospital staff say. The state’s explanation: In the ER, children are technically safe.

The state doesn’t track the number of times hospitals call CPS about children stranded in ERs, officials at the Department of Children, Youth, and Families say. 

At Mary Bridge, the 11 children abandoned in 2021 represent a sliver of the 1,300-1,500 kids who come to its ER each year. These children are among the most vulnerable to show up inside the emergency department, said Jamie Kautz, assistant vice president of the pediatric care continuum at Mary Bridge. 

Seven of the 11, she said, were previously dependents of the state — meaning they were in foster care or group homes. They range in age from 7-17. And they lived in the ER an average of three weeks. One of the abandoned children stayed in the ER for 67 days. One stayed for 40 days. A third was there for nearly a month.

Holding pattern

Many of these children are brought to the ER by adults who assume they have symptoms or behaviors that will qualify them for an inpatient psychiatric bed. But they often don’t. Kautz said abandoned children often have a history of trauma and depression but aren’t in need of inpatient psychiatric hospitalization.

Families refuse to take back their children for often complex and emotionally fraught reasons; many have struggled to get their kids psychiatric help early because of a lack of availability of outpatient care. The child might have difficult or dangerous behaviors that could put their siblings at risk. Some have intellectual or developmental disabilities and their families are unsure how to care for them. They might be in foster care and prone to meltdowns because their home life is unstable. Or the child’s guardians might be so financially or emotionally strained that they feel they have to give up their parental responsibility. 

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Parents of children with developmental disabilities or aggressive behavior face particular challenges, Kautz said. “We are seeing parents with injuries. They want to be safe, they want their children to be safe,” she said. “They know it’s emotionally taxing on their children to be so distressed and physically aggressive in the home. … [They] are invested caregivers, but really they just can’t do it anymore. It requires superhuman ability.”

The decision to leave a child in the ER means they’re occupying a bed that would otherwise be used to serve several patients each day, said officials from the Washington State Hospital Association. When children are ready to be discharged but aren’t, “you are putting intense pressure on the existing resource[s] of the hospitals,” said Chelene Whiteaker, senior vice president of government affairs at the association.

Hospital staff say they work closely with families and state agencies to find a solution. But many social services families used to rely on — state-paid respite care, special education services — were reduced or disappeared during the pandemic when schools closed and in-person services weren’t as easy to receive. Families want their children to be safe but some say they just can’t ensure their safety at home, said Chris Ladish, chief clinical officer of pediatric behavioral health at Mary Bridge.

“You wind up with generally three opposing forces,” she said. “One is a parent saying, ‘You’re not hearing me, I can’t [bring my child home]. You’ve got an ER saying the child is being completely compliant and delightful and we feel they’re ready to come home … so then what happens is you might try to get the state involved.”

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Child in the woods

In the past, case workers from Washington’s Department of Children, Youth, and Families, or DCYF, would take custody of a child abandoned in the ER and work with the family and hospital to find a suitable place for the child to live, hospital workers say. This wasn’t always easy: DCYF’s resources are strained, and the agency has for years sent hundreds of children to sleep in hotels or offices as they wait for more permanent placements. A 2021 court ruling requires the agency to wind down such placements.

But around April 2021, Kautz said, DCYF seemed to change its interpretation of the state’s abandonment law altogether. 

At least two separate areas of Washington law define child abandonment.

There’s the section of state code that Kautz has always looked to. “Abandoned means when the child’s parent, guardian, or other custodian has expressed, either by statement or conduct, an intent to forgo, for an extended period, parental rights or responsibilities despite an ability to exercise such rights and responsibilities,” the law reads.

Then, there’s the section of code DCYF says it uses. A person is guilty of abandonment, the law says, if the person “recklessly abandons the child” and as a result, the child suffers bodily harm. According to DCYF, the section of code Kautz referenced isn’t applicable in cases where parents feel they can’t take their children home from a hospital.

“Kids who are in a hospital, they’re not recklessly abandoned,” said Erik Applebee, a DCYF regional administrator for King County. There’s food, as well as medical providers and security guards. “Reckless abandonment is more like taking a vulnerable child out into the woods and leaving them there where there is an imminent and substantial risk they will suffer bodily harm,” he said.

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DCYF recently consulted with the state Attorney General’s Office on this question, Applebee said. The office declined to answer questions for this article, noting that it doesn’t comment on whether state agencies have asked its legal opinion since part of the attorney general’s role is to provide legal representation for such agencies.

The clashing interpretations of the law have created a fundamental disagreement between hospitals and child welfare officials — one that’s keeping children in a holding pattern without access to regular schooling, exercise, social time or supportive adults. 

Inside the Mary Bridge ER, the 11 children were secluded in 10-foot by 10-foot private rooms without windows or the ability to go outdoors. 

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The story is similar at Sacred Heart Children’s Hospital in Spokane, where one child recently abandoned by their family boarded in the ER for three weeks, said Dr. Breanna Barger-Kamate, an emergency room doctor there. “At some point, people actually really start to deteriorate, like a prisoner of war would,” she said. “You can’t put people in isolation like that.”

When asked about its interpretation of the law, DCYF said the agency is attempting to make its approach to child abandonment cases more consistent, and is now declining to get involved when there’s no allegation of child abuse or neglect.

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Bringing a child into foster care, or temporarily housing them at a hotel, “We think is usually worse for the child,” said Jenny Heddin, director of strategic initiatives and collaboration at DCYF.

“It’s not great for a young person to be boarded in an emergency department or in an institutional setting longer than they need to be there,” she said. “But when they come over to child welfare, typically we don’t have good placement options for those young people either.” 

Kautz said she understands DCYF’s position, but “If DCYF is going to back out on these kids, what takes its place?” 

“These long stays are reflective of not just the complexity of the child’s presentation and family needs,” she said. “But it’s also reflective of the complexity of the shredded social safety net.”

The kids at Mary Bridge eventually were discharged from the hospital. Some returned to their adoptive parents, Kautz said. Others went to live with other family members.

At least one, she said, was sent to juvenile detention.