NBC 7 Investigates: Inconsistencies With County Child-Death Review Teams

A local lawmaker is pushing new legislation to overhaul the system by which all child deaths in California are investigated, reported and analyzed

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Advocates are casting doubts on how California officials look into child deaths, fearing that inconsistencies across the state are leaving some tragedies uncounted. They say a clearer picture could prevent future deaths.

For one great-grandmother, this problem is deeply personal.  

“You’ve got to track what is happening to these children,” Adrienne Arnett told NBC 7 Investigates.

Arnett was discussing the death of her great-granddaughter, whose parents are accused of killing her. She said that from the moment her great-granddaughter, Delilah, was born, she had grave concerns she was in danger in her parents’ care.

“I couldn't get a baby picture, so I called CPS,” Arnett said. “I called and I texted.… I told her, ‘You’ve got to get over there. I know there’s something going on. I know the baby’s in serious danger. You’ve got to go there.’ ”

Last November, Arnett’s worst fears were realized. Baby Delilah died at just three months old. Her parents were charged with first-degree murder. The couple pleaded not guilty and are now awaiting trial. Arnett said that finding justice for Delilah goes beyond the courtroom and requires a closer look at the system.

“If I weren’t making such a fuss about my granddaughter, would anybody even notice it again?” Arnett asked.

San Diego County’s Child Fatality Review Committee will look at Delilah’s case, along with any other sudden unexpected deaths of children. The panel meets monthly to identify factors and circumstances contributing to child deaths. The committee said it uses information from the deaths they review to try to prevent future occurrences, but they don’t report any findings to the state, something that concerns advocates NBC 7 Investigates spoke with.

Dr. Jeoffry Gordon, a child advocate, had plenty to say about how child deaths are investigated, reviewed and reported across the state.

“The lack of attention to this issue, which is snuffing out the lives of small children, is just unacceptable,” Gordon said.

Gordon practiced medicine in San Diego for four decades. Two years ago, he joined the California Citizen Review Panel on Child Fatalities and Near-Fatalities as a Result of Abuse or Neglect. According to the panel’s latest annual report, some counties in the state don’t even have child-death review teams.

“There’s this great void,” Gordon said. “There’s no practical information. There’s no good data.”

By law, every county is required to report all child abuse, and neglect deaths and near-deaths to the California Department of Social Services. In San Diego County, Child Welfare Services said it does that. The state posts those numbers on its website. But Gordon worries that these numbers may be grossly under-reported and would like all child deaths reported to the state for further review.

To make that happen, the Citizen Review Panel is recommending the re-establishment of a statewide child-death review team and the development of a best practices toolkit to assist counties in the local collection of consistent, reliable and complete information.

Also involved in that effort is local California Assemblymember Brian Maienschein.

“Throughout the state, it's been, by and large, very bad," Maienschein said. "San Diego also is behind."

In February, Maienschein filed new legislation to improve the system.

“I think it's very important to find out how many of these deaths are due to abuse, how many of them are due to neglect and to make sure that they're properly investigated to ensure that this doesn't happen to other kids,” Maienschein said.

This issue isn’t new. Five years ago, NBC 7 Investigates told you about state efforts to figure out how many child-death review teams were operating in California.

NBC 7 reached out to the California Department of Social Services and asked if it believed the data was complete. It sent this statement: “In general, underreporting to counties of child abuse and neglect fatalities and near-fatalities is a challenge recognized nationwide that occurs for a number of reasons. In the case of child near-fatalities, child welfare may be made aware of a case but faces challenges in determining the threshold for defining and reporting a near-fatality. In the case of child fatalities, a death that occurs in a household with no siblings may not prompt a call to child welfare, and lengthy court trials may delay reporting. Additionally, data-sharing between coroners, law enforcement and child welfare agencies may also pose a challenge.”

Maienschein’s bill addresses the Citizen Review Panel’s recommendations and would require the attorney general’s office to create a best-practices toolkit and re-establish the statewide child-death review team. The bill also mandates a review team in every county; those teams would be required to post annual reports to their websites.

Gordon said that information would be invaluable to teams like his and could potentially save lives.

“Each one of these deaths is a tragedy,” Gordon said, “but until you can evaluate the whole panorama of what’s going on, you don’t know where to put your effort and energy.”

Arnett said that effort and energy are essential in protecting our most vulnerable.

“It is what is needed,” Arnett said. “Babies should not be dying. Find out what we’re doing wrong not protecting them, how we can protect them, and if we lose them and we fail at that, we need to correct.”

NBC 7 Investigates asked San Diego County multiple times about the family’s warnings to Child Welfare Services about Delilah’s parents. We also reached out to Delilah’s parents for comment concerning the accusations they face. They never responded to us.

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