How Arizona DCS and Catalyst Community Corp lost a child they were paid to protect

In Mesa on July 7, 2024, fifteen-year-old Christian Williams began to fail. He was a Type 1 diabetic in the legal custody of the Arizona Department of Child Safety. He lived in a Catalyst Community Corporation group home that was paid to keep him safe. Insulin keeps a child with Type 1 diabetes alive, and on that day it did not reach him.

The placement was not an accident. Christian’s parents had turned to DCS months earlier because his medical and behavioral needs were more than they could manage at home. DCS placed him in a congregate care setting that promised 24 hour supervision and the ability to manage complex cases. Arizona’s rules place the duty to administer prescribed medication on the licensee, and insulin is not optional care.

By mid June 2024, the record shows the risk was in writing. Catalyst’s manager emailed Christian’s DCS specialist and warned that if Christian “keeps doing this, it will result in his death.” The “this” was refusing insulin. The email asked DCS to act.

Days later, a DCS contracted social worker wrote again, this time asking for a home nurse. She called it “very alarming” if the home did not have the supplies or capacity to meet Christian’s high medical needs. The ask was simple and specific, put skilled nursing at the child’s side or find a placement that can.

An emergency Child and Family Team meeting followed in late June. Catalyst told DCS that Christian needed a higher level of care because of his medical condition and his mental health needs. According to the records, the team agreed that a change was needed. No change was made.

The file shows earlier near misses in that same home. Staff had already sought outside medical guidance for a serious hyperglycemic episode tied to a missed insulin dose. It was not the first time during those weeks. Christian’s mother asked DCS a plain question, “what’s it going to take, for my son to die.”

The rules that applied were neither vague nor hidden. Group homes are required to ensure each child receives all prescribed medication at the prescribed time and in the prescribed dose. When a minor refuses a life sustaining drug, the response must be escalation, physician orders or emergency transport, and a placement review if the home cannot keep the child safe. The record shows documentation of refusals, not consistent escalation.

July 7 is documented across staff statements, call audio, and reports. Christian refused multiple doses over hours, as his blood sugar climbed and his body began to signal distress. He vomited, grew confused, became lethargic. Staff framed it as noncompliance.

The 911 call captured the mindset. “I have a youth that’s refusing insulin or medical help,” the staffer told the dispatcher. She added that he was “making weird noises,” “making a scene,” and “acting like he’s dead on the floor.” The call did not describe a metabolic emergency in progress.

On scene, a Catalyst employee told a Mesa officer, “pretending he’s dead, he’s fine, holding his breath.” First responders found an unresponsive teenager with blue lips and failing respirations. They carried him out of the bathroom, began CPR, and moved him to the hospital. The difference between “acting out” and organ failure was the difference between a staff narrative and a medical reality.

Christian never regained consciousness. On July 10, 2024, after three days in intensive care, he was pronounced dead. The medical examiner certified diabetic ketoacidosis due to inadequate insulin. DKA is preventable with timely insulin and urgent care.

The failure was not isolated to one night. The file shows a sequence that began weeks earlier, warning email, social worker plea, emergency team meeting, no nurse, no move, continued refusals, and a crisis misread as behavior. Each step was a chance to change course. Each step was missed.

This was not Arizona’s first DKA death of a child in state custody. In December 2022, nine-year-old Jakob Blodgett died in a different group home after being allowed to refuse insulin. Two children with the same disease died in two years in the same system for the same reason. The pattern is visible in the state’s own paperwork.

Catalyst’s staff documented refusals, which is a policy requirement. Documentation is not care. When a child refuses insulin, the duty is to move and to act, not to wait and to log. A hospital could compel medically necessary treatment under physician orders, a nurse could escalate, a different placement could meet the need.

Inside DCS, the oversight structure was built to miss what happened next. The Office of Child Welfare Investigations could not fully investigate abuse or neglect by group home staff under the statute that was then in effect. Fatality reviews were limited to abuse or neglect by a parent or guardian. A child died in a licensed facility, and the agency that held legal custody could not produce a public fatality report on the contractor’s care.

Mesa Police conferred with prosecutors and closed their case without charges. DCS’s licensing unit reviewed the group home and announced that the investigation concluded without further action. There were no citations and no sanctions on the license. The placement remained open for business.

The parents did what families are told to do. They filed a notice of claim and then a wrongful death lawsuit against the State of Arizona and Catalyst Community Corporation in December 2024. The complaint alleges negligence and gross negligence. It attaches the June warning email that predicted exactly what happened.

The legislative branch began to repair the hole that the case exposed. In early 2025, Senate Bill 1067 was introduced to give DCS clear authority to investigate abuse in group homes. Another proposal, SB 1333, would allow DCS to require additional qualified staff or nursing support when a medically complex child is placed in congregate care. Lawmakers described missed and ignored red flags that had been written down in this file.

DCS has said it implemented training and contract changes for children with high medical needs. New contract language requires child specific medical training delivered by hospital or home health providers. Providers must attest that they can meet a child’s medical needs or request removal if they cannot. The records released to date do not spell out a bright line protocol that mandates ER transport after each missed insulin dose.

The core failures in this case are specific. A placement warned in writing that a child’s pattern would result in death. A DCS contracted worker asked for a nurse and flagged a lack of supplies. An emergency team met and agreed that a higher level of care was needed. The child stayed where he was, and when the predicted crisis came, the adults closest to him described a dying body as defiant behavior.

Arizona’s administrative rule does not bend for a shift change or a staffing shortage. Prescribed medication must be administered as ordered. For Type 1 diabetes, that rule exists because missed doses put a child on a known path to DKA. To treat refusals as a discipline problem is to choose a path that ends in an ICU and an autopsy.

The on-scene quotes matter because they show how a culture sees a child. “Acting like he’s dead on the floor” is what a staffer said into a phone while a teenager’s blood turned acidic. “Pretending he’s dead” is what another employee told an officer as paramedics prepared CPR. These are not slip ups. They are windows into training, supervision, and priorities.

The oversight outcomes matter because they teach contractors what the state will tolerate. No action by licensing tells providers that documented refusals can neutralize the medication rule. No criminal charges signal that a preventable death can be treated as an unfortunate byproduct of noncompliance. The result is a system that can repeat itself.

There is a policy fix within reach that the records suggest. When a medically fragile child refuses a life sustaining drug, the protocol must be automatic and immediate. Call a physician or call 911 on the first refusal. Transport without delay. If a home cannot or will not do that, move the child that day.

There is also a placement fix that the records imply. Congregate care with rotating staff is ill suited to a disease that requires precision, vigilance, and immediate escalation. If a provider asks for a higher level of care, the answer should be yes unless there is a documented, time bound alternative with on-site nursing. The June emails should have triggered that standard.

Two diabetic children died in Arizona’s foster system in two years. The agency’s response cannot begin and end with training memos and new acronyms. It must produce verifiable changes in practice. It must show in writing who is responsible for the next refused dose and what happens in the next sixty minutes.

Christian Williams is gone. His family is in court. Catalyst’s license is active. DCS says it has updated training and contracts, but it has not published a refusal protocol that would have changed this outcome. The gap between policy on paper and the decisions made on July 7 remains the space where children die.

The file raises questions that the agency should answer with documents, not platitudes. Why did DCS leave a medically fragile child in a placement that asked for a higher level of care. Why did the agency not mandate emergency transport after each missed insulin dose. Why did licensing close without action when the rule requires prescribed medication to be administered and the cause of death was lack of insulin.

Families want proof that the next child in state custody who refuses insulin will be in an ambulance within minutes. They want proof that a warning like “this will result in his death” now triggers a placement change in hours, not weeks. They want proof that DCS can investigate and publish fatality reports when a contractor fails a child, and that the next licensing decision will reflect the next child’s risk, not the last headline.

Christian’s case is not a rhetorical device. It is a set of dates, emails, calls, and medical facts that describe how a system failed to do what it was paid and empowered to do. The documents show what went wrong. The absence of swift and documented corrective action shows what can go wrong again.

If you have shift logs, emails, policy memos, training decks, incident reports, or body camera footage that shed light on this case or similar cases, send them to fuckdcf.paul@pm.me