GRAND RAPIDS, Mich. (WOOD) — The murder-suicide deaths of a 39-year-old Grand Rapids woman and her 11-year-old son exposed flaws in the system that was meant to protect the boy from his suicidal mom, according to a report from the Michigan Office of Children’s Ombudsman.

The woman shot her son before turning the gun on herself while vacationing in Mackinaw City in June 2020, according to the report. Her boyfriend found their bodies in a shed near their hotel.

She had been threatening murder-suicide for weeks and was being investigated by the Kent County Children’s Protective Services office, according to the report.

While the office found “the death could not be prevented through CPS action,” it also said it “illustrates the need for policy and law enhancement… to make similar deaths less likely in the future,” the report states.

The state Ombudsman report details the months leading up to the deaths: a mom suffering from depression and anxiety, repeated suicide attempts and a family fighting to get her help.

Records show that the mom saw at least seven mental health providers in the months leading up to the deaths.

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The Kent County CPS office opened a possible child abuse investigation in April 2020 after she talked of killing herself and her son. She had already tried overdosing on pills, tried to cut her wrists with keys, tried jumping in front of moving traffic and from a moving vehicle, the report states.

That was two months before the deaths. She had been admitted to Forest View Hospital.

The report shows CPS closed that first investigation in early May 2020 because she was seeking mental health care and was in the care of her father.

But the ombudsman report suggests CPS didn’t have the full story.

The ombudsman investigation found that Forest View Hospital refused to turn over the woman’s mental health records to CPS because she “refused to sign a release of information.”

That goes against state law, which requires the hospital turn it over, consent or not, in cases involving possible child abuse or neglect, the report states.

The investigation also found that the Kent County CPS office did not rely on the state law to push for the records.

Then, just a week before the deaths, police were called after the mom had been “researching ways to kill her son and herself.”

She was taken to Mercy Health St. Mary’s but released the same day “because she denied making suicidal or homicidal comments about herself or her son…”

That led CPS to open the second investigation, which was still open at the time of the deaths.

The ombudsman wrote that CPS policy is flawed because it “does not offer concrete ways to address a caregiver’s mental health and its effect on a child’s safety.”

Among the changes recommended by the report: better training for CPS workers dealing with mental health records; new laws to require more training for mandatory reporters of suspected child abuse and to require mental health workers to turn over records in a week. Right now, they have two weeks.

“The OCO (Office of Children’s Ombudsman) finds that for the better protection of children at risk of harm, CPS must secure mental health records in a timely manner and be given adequate time to review these records thoroughly accurately,” according to the report.

In its response to the investigation, The state Department of Health and Human Services, which operates CPS, said it agrees with most of the recommendations.

If you are in crisis, you can reach the National Suicide Prevention Lifeline anytime at 1.800.273.8255.