A Child at Risk: Missed Opportunity to Save a Life*

involved with child abuse that would help those agencies to discern patterns of abuse. Response: Disagrees wholly with the finding The Social Services Agency (SSA), Child Abuse Registry (CAR) is responsible for maintaining a centralized index of child abuse reports that are filed within Orange County. Information contained in prior reports is evaluated in determining patterns and responses to subsequent allegations. Further, SSA regularly dialogs and coordinates services with law enforcement, health care professionals, and other agencies involved in child abuse prevention, assessment, and/or intervention to the extent that confidentiality laws will allow. This liaison can also alert SSA to at risk children and families who have not yet been brought to the attention of SSA, but who have received services from other community agencies, or service providers. At the time of this child's death, the Child Abuse Registry has no policy to 2. document all incoming calls on child abuse Response: Disagrees wholly with the finding SSA's policies, procedures, and practices have been and continue to require that all incoming calls on child abuse be logged. Excerpts from the SSA's Children and Family Services (CFS) Operations Manual Procedure Number D-0102, approved November 30, 1993: The telephone report is to be recorded by the CAR SSW (Senior Social Worker)... The SSW shall record all available and appropriate information on the Child Abuse Report... The Child Abuse Registry and Emergency Response Programs have a vacant 4. position for a public-health nurse to gather, evaluate and interpret medical information. Response: Agrees with finding Exhibit 2 Mandated reporters failed to contact the Child Abuse Registry to report injuries to 5. the FCV and a sibling, delayed in reporting those injuries to CAR and did not follow up with written reports. Response: Disagrees partially with the finding SSA's records indicate two mandated reporters made child abuse reports approximately four and one-half months and three months prior to the child's death. Subsequent concerns/incidents were not reported to CAR in verbal or written form prior to the child's death. The child-advocacy home made a call to the Child Abuse Registry on or about Jan. 6. 22, 2002, reporting new injuries to the FCV, but no documentation of that telephone call exists. Response: Disagrees wholly with the finding SSA's policy, procedure, and practice have been and continue to require that all incoming calls on child abuse be logged. The practice of inputting all telephone calls from mandated reporters into a computer database began in July 2003. Prior to that time, these calls were either entered onto a paper log if no child abuse report was generated, or onto the computer database if the information received warranted a child abuse report be generated. The explanation provided in response to Finding 2 provides relevant details. If the call had been received, it would have been logged. Despite the inability of the Social Services Agency and the Anaheim Police 7. Department to confirm abuse of the FCV, an aggregation of facts/observations might have revealed a pattern of abuse. Response: Disagrees partially with the finding SSA substantiated one of the two referrals received. If mandated/ non-mandated reporters had filed subsequent reports, the cumulative information would have been assessed for a pattern of abuse. Children and Family Services failed to conduct an internal Child Death Review 8. involving a meeting of parties/agencies associated with this case. Response: Disagrees wholly with the finding SSA's Quality Development Program conducted an intra-agency child death review for this case that included a comprehensive review of the facts, interviews with protagonists, and the presentation of findings to the Juvenile Justice Commission. In addition, the Orange County Child Death Review Team-headed by the Coroner's Exhibit 2 Office reviewed this case. The Child Death Review Team includes representatives from the Orange County Department of Education, the Probation Department, Sheriff/Coroner's Office, Health Care Agency, law enforcement agencies, SSA management staff, and other stakeholders.

The Social Services Agency increase its education of mandated reporters, with an emphasis on state-mandated requirements, penalties for non-compliance and guidance on recognizing and reporting child abuse. Response: The recommendation has been implemented CAR is responsible for providing mandated reporters in Orange County with information about their mandated responsibilities. To this end, CAR maintains a Speakers Bureau through which community based organizations, educators, health care providers, law enforcement agencies and any other organization or individual considered to be a mandated reporter under California law can request educational materials or a speaker to address a group. During 2003, SSA provided informational training to an average of 226 mandated reporters per month. In addition, SSA continues to look for ways to enhance the dissemination of information regarding reporting responsibilities. A recently developed informational video highlighting child abuse signs and reporting responsibilities is being disseminated. The Agency will issue a notice by September 30, 2004 to schools, agencies, medical professionals, community/faith-based organizations and other mandated reporters outlining the signs of child abuse and neglect, reporting responsibilities, and offering a variety of educational materials. Children and Family Services conduct a forum-type Child Death Review in every 6. case where the child dies from abuse or under suspicious circumstances. Involved in the review would be all participants associated with the case, such as social workers, police officers, relatives or teachers. Response: The recommendation has been implemented Child deaths involving dependent children, or those children who have died from abuse or under suspicious circumstances are currently reviewed using three different systems. SSA conducts an intra-agency review. The process involves gathering information about the family and the circumstances of the child's death from case records, interviews with SSA staff, interviews with health practitioners, counselors, law enforcement, and other professionals involved with the family. At the conclusion of this review, a report is written by a SSA supervisor. This procedure was established by SSA in 1994. Secondly, SSA staff meets with Exhibit 2 members of the Juvenile Justice Commission (JJC) to review each report and to discuss collateral issues related to the child's family or child's death. SSA and JJC staff began these meetings in the late 1990's. In addition, SSA participates in the Orange County Coroner's Child Death Team. The Coroner's Child Death Team reviews all cases where a dependent child has died, a child who has died under suspicious circumstances, or those children whose death has otherwise been referred to the Coroner's office. The Coroner's Child Death Team was established in 1987.

The Child Abuse Registry add a public-health nurse to assist social workers at CAR in interpreting and evaluating medical information on children who come to the attention of Children and Family Services Response: The recommendation has not yet been implemented, but will be implemented in the future SSA received authorization to hire a Senior Public Health Nurse (SPHN) on June 4, 2004, who will assist social workers at CAR in interpreting and evaluating medical information. The SPHN will be in place by December 31, 2004 or earlier.

In lieu of a roundtable gathering, a single senior social worker was assigned to prepare a written report. A social worker who visited the home and examined the child was never interviewed for the report. Response: Disagrees wholly with the finding SSA's Quality Development Program concluded an intra-agency child death review and written report for this case on June 17, 2002. The process included interviews with all social workers that visited the home. A member of SSA supervisory staff prepared the written report.

Because law enforcement agencies frequently call in on the public phone line rather than the dedicated line at the Child Abuse Registry, they experience delays in getting information on prior reports of child abuse. Response: Disagrees partially with the finding SSA has a dedicated telephone line and staff to manage requests from authorized authorities for prior child abuse records. Some law enforcement personnel directly contact the CAR for prior report information. Registry calls are sequenced in order of receipt to the next available social worker. Depending upon the number of other calls, they may experience delays in getting information. The average current wait time for callers is 1 minute and 11 seconds. Response to Recommendations 1-6 & 8-10: The Child Abuse Registry expand its database capability to include all incoming 1. calls. Add sufficient resources to accommodate this additional workload. Response: The recommendation will not be implemented because it is not warranted CAR receives thousands of telephone calls each month from both mandated and non-mandated reporters. These calls involve child abuse reporting, consulting, requests for community resources or referrals, and other types of information. All of these calls are currently logged. It would not be prudent or legal to enter these calls as suspected child abuse referrals into CWS/CMS. Exhibit 2 The Social Services Agency assume a leadership role in establishing a mechanism 2. for gathering and disseminating information among the Social Services Agency, medical providers, law enforcement and other agencies involved with children. Response: The recommendation has been implemented SSA has assumed a leadership role in coordinating and disseminating information and services to children. CAR is responsible for maintaining a centralized index, processing and distributing child abuse reports to local and state law enforcement agencies. Also, SSA staff routinely coordinates assessments and interventions with medical providers, law enforcement and other agencies involved with children. A prime example of this approach is the Children's Services Coordination Committee (CSCC). The CSCC has eighteen members from both the public and private sector in Orange County. The CSCC was first organized in 1998. In 2000, the operation of the CSCC was officially recognized by Board of Supervisors. The CSCC meets on a monthly basis, and is facilitated by the Director of Children and Family Services. Its responsibilities include identifying gaps and barriers in services to children, and recommending collaborative and system-wide improvements. The Social Services Agency work more closely with larger medical institutions that 3. use Suspected Child Abuse/Neglect (SCAN) teams in detecting child-abuse injuries and developing procedures for recording and reporting abuse. The Social Services Agency should also include those medical providers that do not use SCAN teams. Response: The recommendation has not yet been implemented, but will be implemented in the future SSA oversees the Child Abuse Services Team (CAST). In collaboration with the Health Care Agency and under contact with the University of California, Irvine Medical School, CAST will be hiring a Medical Director. The duties of this licensed physician will include working closely with all medical professionals and health care providers in the community, to assist in the early detection of child abuse injuries and the further development of procedures for recording and reporting abuse. The hiring of a CAST Medical Director will further enhance the ability of CAST to provide services to the community. A recruitment for this position is currently in process. The CAST Medical Director should be employed by December 31, 2004 or earlier. The Social Services Agency provide timely updates to law enforcement on changes 4. in laws that reflect the release of confidential information for cases covering child abuse. Response: The recommendation will not be implemented because it is not warranted Exhibit 2 ٠ The State Attorney General's Child Protection Program (Department of Justice (DOJ)) administers the Child Abuse Central Index and assists district attorneys, local law enforcement, and child welfare and probation agencies in the administration of justice, including protecting the health and safety of California's children. Changes in Child Protection Program Statutes/Regulations are disseminated directly to child welfare/law enforcement agencies via Informational Bulletins (notices). SSA receives notice of these changes, and provides training to staff on a continual basis.