California has lost ground in the ranking of states whose juvenile court and child welfare systems operate in transparency, and the result is a persistence in the deaths of children while wards of the counties, says a newly released study, “State Secrecy and Child Deaths in the U.S.”  The resulting C+ grade—down from an A- in the first such survey and compared with Nevada’s current A+—is documented in the excerpt below, which shows the number of points possible for each item, preceded by the number of points actually achieved.  The full report provides more context.

I. Is there a state policy regarding public disclosure of findings or information about child abuse or neglect which has resulted in a child fatality or near fatality?

Yes.
40 out of 40

II. Is the state policy codified in statute?

Yes as to fatalities (Cal. Welf. & Inst. Code §10850.4, Gov. Code § 6252.6). No as to near fatalities (policy is contained in Department of Social Services (DSS) All County Letter No. 08-13 & 10-06).
8 out of 10

III. What is the ease of access to the information?

California’s policy regarding information on fatalities is mandatory with severely restrictive conditions. California’s statute requires release of
some information, upon request, when there is a “reasonable suspicion that the fatality was caused by abuse or neglect” (Cal. Welf. & Inst. Code § 10850.4 (a)) and, upon request, the release of more probative information upon the completion of the investigation of abuse or neglect that has led to a child’s death (Cal. Welf. & Inst. Code § 10850.4(c)). According to the statute, “[a]buse or neglect is determined to have led to a child’s death” if a county child protective services agency determines that the abuse or neglect was substantiated; a law enforcement investigation concludes that abuse or neglect occurred; or a coroner or medical examiner concludes that the child who died had suffered abuse or neglect.

However, when it comes to releasing the more probative information, California’s implementing regulations impose the additional requirement that either (1) the child resided with his/her parent or guardian, and the abuse and/or neglect was inflicted by the parent or guardian; or (2) the child resided in foster care, and the abuse and/or neglect was inflicted by the foster parents (California Code of Regulations, Reg. 31-502.33, 31-502.34, 31-502.35). California’s “All County Letter” policy regarding the release of information on abuse or neglect
death and near fatalities is mandatory (the report “shall” be available to the public upon request).
8 out of 20

IV. What is the scope of information authorized for release?

California’s policy regarding abuse or neglect deaths has substantial breadth. Within five business days of learning that a child fatality has
occurred in the county and that there is a reasonable suspicion that the fatality was caused by abuse or neglect, the information to be disclosed includes the age and gender of the child; the date of death; whether the child was in foster care or in the home of his or her parent or guardian at the time of death; and whether an investigation is being conducted by a law enforcement agency or the county child welfare agency (Cal. Welf. & Inst. Code § 10850.4(a)). If upon completion of the investigation into the child’s death it is confirmed that abuse or neglect occurred, the following documents are also available: all previous referrals of abuse or neglect of the deceased child while living with his/her parent or guardian; the emergency response referral information form and the emergency response notice of referral disposition form completed by the county child welfare agency relating to the abuse or neglect that caused the death of the child; any cross reports completed by the county child welfare agency to law enforcement relating to the deceased child; all risk and safety assessments completed by the county child welfare services agency relating to the deceased child; all health care records of the deceased child, excluding mental health records, related to the child’s death and previous injuries reflective of a pattern of abuse or neglect; and copies of police reports about the person against whom the child abuse or neglect was substantiated. Additional documents are available if the child’s death occurred while the child was in foster care (Cal. Welf. & Inst. Code § 10850.4(c)). The custodian of records must redact the names, addresses, telephone numbers, ethnicity, religion, or any other identifying information of any person or institution, other than the county or DSS, that is mentioned in the released documents (Cal. Welf. & Inst. Code § 10850.4(e)); however, for children who die from abuse or neglect while in foster care, Cal. Gov. Code § 6252.6 authorizes the release of the child’s name to the public upon request.

California’s policy regarding near deaths caused by abuse or neglect, as contained in DSS’ All County Letter No. 08-13 (March 14, 2008) (which also pertains to deaths), is narrow. Regarding near fatalities, data collected in DSS’ “Statement of Findings and Information” is limited to the child’s age and gender, the date of the near fatality, where the child resided at the time of the incident, whether law enforcement or CWS/probation conducted the investigation, and whether a physician, law enforcement, or CWS/Probation determined that it was caused by abuse/neglect. The form explicitly prohibits counties from providing any narrative regarding the case.
17.5 out of 20

V. Are child abuse/neglect proceedings open?

Cal. Welf. & Inst. Code § 346 provides unless otherwise requested by a parent or guardian and consented to or requested by the minor
concerning whom the petition has been filed, the public shall not be admitted to a juvenile court hearing. The judge or referee may nevertheless admit such persons as he deems to have a direct and legitimate interest in the particular case or the work of the court.
5 out of 10*

VI. What’s changed in California since the 1st Edition of State Secrecy and Child Deaths in the U.S. was released in April
2008?

In the April 2008 State Secrecy Report, California’s score was 92 (rounded up from 91.5) earning it an A– . Since then, California has released implementing regulations (California Code of Regulations, Reg. 31-502.33, 31- 502.34, 31-502.35) which place several severely restrictive limitations on the mandatory release of information regarding child fatalities, such as specific requirements regarding the child’s residence as it relates to the perpetrator of the abuse.

Illuminating Information:
•• Under California’s statutory scheme, abuse or neglect is determined to have led to a child’s death if either (1) “[a] county child protective services agency determines that the abuse or neglect was substantiated” (2) “[a] law enforcement investigation concludes that abuse or neglect occurred” or (3) “[a] coroner or medical examiner concludes that the child who died had suffered abuse or neglect. California’s regulations, however, insert a requirement that the evident abuse and neglect suffered by the child be ruled to be what caused the child’s death before information can be released.
•• DSS’ 2010 All County Letter No. 10-06 requires counties to complete and submit a “Statement of Findings and Information” to DSS for cases of child fatalities and near fatalities only when it “is determined” that the incident occurred as a result of abuse or neglect. For child fatalities that are “suspected” to be the result of child abuse and/or neglect, counties are still required to release limited information upon public request. There is no requirement for release of information regarding near fatalities unless and until the near fatality is determined to be the result of child abuse or neglect.
•• While California’s policies are somewhat problematic, their implementation has even greater challenges. In Los Angeles County, for example, the Office of Independent Review found a “pattern of non-disclosure” where blanket objections to the release of information were lodged in 17 of 19 cases in 2009 and 2010, leading to the non-disclosure of information. CAI is pleased that the Los Angeles Times and the Los Angeles Board of Supervisors have continued to look into the problem of non-disclosure but we are concerned that this pattern may not be limited to Los Angeles County.
•• Across the state of California, public disclosure of findings and information about child abuse or neglect which has resulted in a child fatality has caused scrutiny of systemic problems. At a County level, Sacramento County, Los Angeles County, and others have accepted responsibility where appropriate and are making changes to problematic child welfare policies.
•• In Los Angeles County (the county with the largest foster care population in the nation), the Presiding Judge of the Juvenile Court issued a local court order in early 2012 clarifying when the press and public may have access to dependency court proceedings. Local press has utilized this clarification to gain access to dependency courts and give the public information on the Dependency Court process.

Meanwhile the report salutes the coverage of three investigative journalists as rare examples of the press paying focused attention.

The liberalization of public information about child abuse deaths has had benefits in California, where legislation providing for more complete disclosure of child deaths from abuse has yielded important examples of system flaws (not merely the idiosyncratic error), and reforms leading to more refined and correct removal decisions. Since 2008, extraordinary journalists, including Greg Moran in San Diego, Garrett Therolf in Los Angeles, and Marjie Lundstrom in Sacramento, have used multiple examples of system failure leading to child deaths to spark improvement:
•• In the San Diego Union-Tribune, Greg Moran presented the results of that newspaper’s review, preceded by years of petitions in court and Public Records Act requests, of cases that “illuminate weaknesses in the system, including gaps in communication and in enforcement of regulations.” He reported on the lack of information exchange in the transfer of foster kids between placements that led to dangers and deaths.
•• Sacramento Bee journalist Marjie Lundstrom reported on multiple errors by Sacramento CPS and child deaths, leading to her 2011 coverage of corrective efforts: “A searing internal review of Sacramento County’s Child Protective Services has concluded that judgment errors and bias among agency workers were factors in the 2008 death of a 4 1/2-year-old foster child.”
•• Garrett Therolf’s series of stories in the Los Angeles Times exposed systemic flaws in the nation’s largest county. His research revealed a 2008 case involving a severely abused 5- year-old boy. Eight agencies had more than 100 contacts with his family, but those findings were not shared. “When the boy was finally removed from the home, he was so malnourished that his kidneys were failing, his hands burned so badly that he could barely unclench them.” In another case, Los Angeles County mental health and child abuse investigators visited an 11-year-old boy who had told a school counselor earlier that daythat he wanted to kill himself. After speaking to the boy privately at his home, the county workers left. A few hours later, the boy hanged himself. According to Therolf, “[a] review following [the] suicide uncovered evidence that persistent communication breakdowns at the county Department of Children and Family Services may have contributed to the tragedy.” For example, “[i]t was not until after [the boy] killed himself that the workers learned that the stepfather who answered the door had a long history of drug abuse and domestic violence. He was there when county officials visited, even though a court order barred him from living in the home.”15 The examples and detailed documentation provided by Therolf has stimulated agency reforms.