Sheriff-coroner Department County of Orange California Michael S. Carona Sheriff-coroner*

The OCCDRT is not intended to be an investigative body or oversight committee that directs an investigation or directs a specific agency's response. Rather, the OCCDRT's purpose is to 1) learn from each case about how the provision of services and the investigation was accomplished, what worked well, and what could have been improved, and 2) to recommend improvements in the provision of services and/or investigations that will help members of the team to become more effective or efficient in future cases. If system gaps or inefficiencies are identified during OCCDRT's retrospective review, then recommendations for improvements will be made and follow up action will be taken for future cases.

Accurate and timely interagency communication is a long-standing practice among Orange County agencies. When a child death occurs, no meeting is required in order for critical information exchange to take place. The OCCDRT has been meeting since 1987. Improved communication and coordination between agencies was targeted by the early team. This early work of the OCCDRT has borne fruit so that today, agencies systematically contact each other to gain and share information throughout the normal course of their investigations and delivery of services. 7.2 CDR oversight: Probation should broaden representation in its reviews by including the JJC. The OCCDRT should include representation of the Grand Jury. Written results of Probation and SSA reviews should be submitted to the OCCDRT for final disposition, for follow-up action if appropriate, and to support any preventative measures. (See Finding 6.2) The Sheriff-Coroner will not respond to the recommendation addressed to the Probation Department. The recommendation to include representation of the Grand Jury on the OCCDRT will not be implemented. State law makes the information reviewed by child death review teams confidential (e.g., Welfare and Institution Code section 830 and 10850.1; Penal Code section 11167 and 11167.5.) Indeed, specific legislation, Penal Code section 11170 (b)(5) and Welfare and Institution Code section 10850.1, was necessary to enable child death review teams to have access to the confidential information and to share it among themselves. This same legislation only authorizes child death review teams to re-disclose the information to "other child death review teams." (Penal Code section 11170(b)(5), and provides that "[a]II discussions relative to the disclosure or exchange of any [confidential] information or writing during team meetings are confidential ..." (Welfare and Institution Code section 10850.1). Maintaining this strict confidentiality enables agencies having responsibility for the investigation of child deaths and those having responsibility for protecting the health and welfare of children to share freely and candidly otherwise confidential information that may be critical to protection of siblings of dead children and other children who might fall victim to the same perpetrators or other causes of child death. The inability of key agencies to lawfully share confidential information prior to 1988 had negative effects on the detection, investigation and prosecution of child abuse and neglect cases. California recognized this as a deficit and enacted legislation (Penal Code section 11174.32 and 11174.33) to facilitate this much-needed communication by authorizing each county to establish an interagency child death review team made up of multidisciplinary personnel. Welfare and Institution Code section 18951 (d) defines multidisciplinary personnel as those who are trained in prevention, identification and treatment of child abuse and neglect cases and who are qualified to provide a broad range of services related to child abuse. The Attorney General's office has opined that the decision to allow or not allow the Grand Jury to attend a CDRT meeting is a local issue to be resolved by either the district attorney or the county counsel. Because of the strict confidentiality State statutes require for much of the information reviewed by OCCDRT, and the need for candid exchange of information among the agencies participating in OCCDRT, the County Counsel for the County of Orange has advised against Grand Jury representation. It is also noted that no CDRTs in California permit Grand Jury representation on their team. Finally, the Grand Jury's participation in CDRT meetings, many of which involve homicides, could compromise the Grand Jury's potential role as the body from which indictments might be sought relative to the same homicides. 7.3 CDR membership: The Probation Department should broaden representation in its reviews by adding the HCA, DA, and one or more community child welfare organizations. The SSA should broaden representation in its reviews by adding the Coroner Division, HCA, and DA. The OCCDRT should memorialize in its member manual approved agencies and consider additional community child welfare organizations. (See Finding 6.3) . . The Sheriff-Coroner will not respond to the part of the recommendation addressed to the Probation Department and SSA. The recommendation that the OCCDRT should memorialize approved agencies in its member manual will not be implemented by the OCCDRT. A list of approved agencies attending the OCCDRT meetings is equivalent to the member roster, which is already included in the member manual and updated regularly. The recommendation that the OCCDRT should consider additional community child welfare organizations is a continuing consideration for the team and has long been implemented on a limited basis. The Sheriff-Coroner does not believe any change from the current method of implementation is warranted. The membership of the core OCCDRT must meet the legal definition of multidisciplinary personnel described in the Welfare and Institutions Code Section 18951(d). The OCCDRT believes that an effective number and type of community child welfare organizations currently are represented within the core team membership. In the rare instance when a death involves a specialty group that is not represented, the team forms subcommittees that pull members from different agencies and groups to address specific issues. 7.4 OCCDRT practices: The OCCDRT should revisit and reconsider the case selection process and time spent to review each selected case. (See Finding 6.4) This recommendation will not be implemented by the OCCDRT. The OCCDRT case selection criterion is based on deaths reported to the Coroner of children less than 18 years of age. The Sheriff-Coroner believes the current OCCDRT selection process is appropriate. The OCCDRT appreciates the opportunity to respond regarding the time spent by the OCCDRT to review each case. As stated in the response to finding 6.4, many cases are reviewed for months, sometimes for longer than a year. The cases may undergo extensive internal reviews by the respective agencies in addition to the many months spent in review by the OCCDRT. The Sheriff- Coroner believes the amount of time spent reviewing each case is sufficient and appropriate. The OCCDRT review process is as follows: Members receive demographic information and detailed circumstances of the death from the coroner's records approximately 30 days prior to the meeting.

CHILDREN'S NETWORK COUNTY OF SAN BERNARDING 385 North Arrowhead Avenue, Second Floor • San Bernardino, CA 92415-0049 KENT PAXTON (909) 387-8966 • Fax (909) 387-4656 Network Officer July 19, 2006 Jacque Berndt Chief Deputy Coroner 1071 W. Santa Ana Blvd. Santa Ana, CA 92703 Dear Ms. Berndt: Children's Network is the Interagency Council of San Bernardino County, and was the model for the state legislation in 1986, which mandates Interagency Councils, be created in all 58 counties. As the Chairman of the Southern Regional Child Death Review Team, member of the State Child Death Review Council and the lead staff for the San Bernardino County for the Child Abuse Prevention Council, as well as the co-chair of the San Bernardino County Child Death Review Team, I strongly support your position regarding the Orange County Grand Jury Report. County Counsel for San Bernardino County has consistently advised against allow any outside participation in these extremely confidential and highly sensitive meetings. Discussions during these meetings are intended to identify issues, which could negatively impact other children within the family, or in the community, and to provide protective factors to ensure all children's safety. Further, because the Grand Jury, by mandate, is an investigational body, and they are compelled to base questions from that perspective, their attendance in these meetings would change the entire focus and members of the team may be unable to attend based on County Risk Management policies. Additionally, the Superior Court issued the Standing Order by which San Bernardino County bases its sharing of confidential information, and all Grand Juries are appointed by the Superior Court; we wonder why the Grand Jury has issues with this process when the court does not. POLICY COUNCIL MEMBERS Arrowhead Regional Medical Center County Counsel Member of the Board of Supervisors Sheriff-Coroner Behavioral Health Department County Library Superintendent of County Schools Preschool Services Department Department of Children's Services Transitional Assistance Department Children's Fund Presiding Judge, Juvenile Court Community Action Partnership District Attorney Probation Department ; This issue is one that the State CDR Council has discussed at some length, and I recommend that you ask the Council to weigh in on this report and your response. I hope this letter is helpful to you as you respond to the GJ report. Thank you for the opportunity to share my perspective based on my experience and interaction with other teams. Sincerely, Susan G. Melanson Susan Melanson t Response to Grand Jury Report 2005-2006 "When Will We Be Free of Preventable Childhood Deaths?" August 2006 SHERIFE Michael S. Carona Sheriff - Coroner ORANGE COUNTY SHERIFF'S DEPARTMENT ; When Will We be Free of Preventable Childhood Deaths FINDINGS In accordance with California Penal Code §933 and §933.05, responses are required to all findings. The 2005-2006 Orange County Grand Jury arrived at the following seven findings. Beneath each is the Sheriff's Department response to those findings. 6.1 Child death review (CDR) timeliness: The county practice is to hold CDRs on all in-custody and related deaths. The Probation Department procedure is to hold a Post Incident Medical and Operational Review within 10 days of a death. The Social Services Agency (SSA) procedure is to hold semi-annual CDRs. The Orange County Child Death Review Team (OCCDRT) procedure is to hold quarterly CDRs. The Sheriff-Coroner will not respond to the findings addressing the Probation Department and the Social Services Agency. The Sheriff-Coroner agrees with this finding as it relates to the Orange County Child Death Review Team (OCCDRT) procedure to hold quarterly CDRs. 6.2 CDR oversight: The county practice generally does not provide for public oversight of CDRs. As required by a court order, however, the Juvenile Justice Commission (JJC) participates in SSA CDRs. The Probation Department procedure does not permit public oversight. The OCCDRT does not provide oversight of any county CDR and does not permit Grand Jury oversight of its activities. The Sheriff-Coroner will not respond to the findings addressing the Probation Department and the Social Services Agency. The Sheriff-Coroner agrees with the finding that the OCCDRT does not provide oversight of any county child death review other than that conducted by the OCCDRT. The Sheriff-Coroner also agrees with the finding that the OCCDRT does not permit Grand Jury oversight of the OCCDRT. 6.3 CDR membership: The Probation Department includes no representation from the District Attorney (DA), HCA, or child welfare organizations. Other than the JJC, SSA includes no other representation. The OCCDRT includes no representatives from the OCH and very limited community child welfare organization representation. The OCCDRT maintains no approved agency list. The Sheriff-Coroner will not respond to the findings addressing the Probation Department and the Social Services Agency. The Sheriff-Coroner agrees with the finding that the OCCDRT has no representatives from the OCH. The OCCDRT has limited community child welfare organization representation and maintains no approved agency list. 6.4 OCCDRT practices: During 2005, the OCCDRT only spent an average of 21/2 minutes per child death. The Sheriff-Coroner disagrees with this finding. Many cases are reviewed by the OCCDRT for months, sometimes for longer than a year. There is no set period of time for review of a case. Rather the length of the review period is as long as is needed to thoroughly address the issues raised by the facts of each individual case. 6.5 OCCDRT process: The OCCDRT is not in compliance with its own member manual, which indicates responsibilities for publication of annual reports and development of preventive efforts. The OCCDRT does not create meeting minutes. The Sheriff-Coroner disagrees with this finding to the extent it states that the OCCDRT is not in compliance with its own member manual. The member manual was not implemented until April 2005. Since then, OCCDRT has worked actively to accomplish the member manual's stated goal of publishing an annual report. The first annual report is scheduled for release in the fourth quarter of 2006 and will cover the data collected during the 2005 year. Regarding the development of preventative efforts, the OCCDRT has been very active in providing training related to child deaths and mandated reporting to law enforcement and the medical community. Promoting increased awareness of reporting responsibilities, recognition of child abuse indicators, and understanding of the various services available all result in an improved system response, which leads to prevention. Additionally, as a result of interagency sharing of information through the OCCDRT, several agencies have modified or implemented new procedures to strengthen intra-agency response and to better apply their internal resources where needed. The Sheriff-Coroner agrees that the OCCDRT does not create meeting minutes. 6.6 OCCDRT training: No internal training is provided to incoming members of the OCCDRT. There is only limited utilization of state training per Penal Code § 11174.32 based on the availability of state stipends. The Sheriff-Coroner disagrees with this finding. Team members are multi-disciplinary personnel as defined in Section 18951(d) of the Welfare and Institutions Code. In accordance with that Code section, all OCCDRT members already "are trained in the prevention, identification and treatment of child abuse and neglect cases and ... are qualified to provide a broad range of services related to child abuse." In addition to the fact that all team members already possess the essential expertise and knowledge needed to be on the team, they are also provided a member manual which defines the team's purpose and objectives, explains the processes used for case review and describes their role and responsibility as team members. Accordingly, the limited public resources available for the prevention of child deaths are much better expended on actual prevention efforts than on duplicative training of OCCDRT members who already are experts in the field. Formal instruction about how to be a team member is unnecessary and would be a misuse of limited resources. Penal Code § 11174.32 does not address training or stipends; however PC §11174.34 mentions training. Members of the OCCDRT attend the State-sponsored training based on the members' availability. In May 2006, the Orange County Sheriff-Coroner hosted the State- sponsored training, which was heavily attended by the OCCDRT members. 6.7 OCCDRT resources: Other than possibly using state income from FCANS reports, the OCSD does not provide funding for OCCDRT activities. The Orange County Sheriff-Coroner disagrees with this finding. The OCCDRT is a multi-agency group comprised of at least eleven different county agencies/groups working collaboratively to support the objectives and purpose of the team. The Orange County Sheriff-Coroner Department is the single largest contributor of resources to the OCCDRT, although each other participating agency and/or group contributes some of its personnel and resources. The Chief Deputy Coroner acts as Chairperson of the OCCDRT. At least three other Coroner Division staff members spend many hours preparing for and participating in the quarterly meetings. The computerized data storage is handled by OCSD Systems Division personnel. In March of 2005, the Sheriff-Coroner hired a new Research Analyst in the Coroner Division for the purpose of collecting and analyzing more specific data and developing the annual report for the OCCDRT. OCSD provides the facility for the quarterly CDRT meetings, all subcommittee meetings and hosted the recent May training attended by over 50 professionals. Finally, all miscellaneous resources used by OCCDRT, such as paper, notebooks, vehicles to deliver confidential pre-meeting packets, computers and other equipment, come from the Sheriff-Coroner budget.