When Will Be Free of Preventable Childhood Deaths?*

report to follow within eight hours. Law mandates that the Coroner will be immediately notified. (Note: The a. Coroner Division of the Sheriff-Coroner Department should be contacted directly. Contacting the Sheriff's Watch Commander is not proper notification to the Coroner.) The Coroner will respond immediately to the scene of the death of a minor b. in custody. The local Chief of Police (if the institution is within the city limits of an 2. incorporated city) within a reasonable time but not to exceed two hours. The District Attorney as soon as a member of the District's Attorney's Office is 3. on duty and in writing within 24 hours. The Presiding Judge of the Juvenile Court by telephone, with follow-up in writing 4. within 24 hours. The Chairman of the Juvenile Justice Commission by telephone, with follow-up 5. in writing within 24 hours. The Departmental Safety Officer by telephone, with follow-up in writing within 6. 24 hours. The County Risk Management Manager by telephone, with follow-up in writing 7. -ಕ್ರಾಕ within 24 hours. Clerk of the Board of Supervisors in writing within 24 hours (or Chairman of the 8. Board of Supervisors immediately, if "exceptional circumstances" exist). The County Executive Officer in writing within 24 hours.

Further, Section IV of Procedure 3-1-106 - Post Incident Medical and Operational Review, Subsection C notes: "A medical and operational review will occur within 10 days following an in-custody death of a minor. The review team shall include the Chief Probation Officer, Chief Deputy of Institutional Services, the Institutional Director of the involved institution, and other administrative and supervisory staff relevant to the incident including but not limited to the responsible physician (HCA), the nursing supervisor (HCA), legal counsel, the coroner staff involved, etc." In summation, any death of a minor in custody in an Orange County Probation Department Institution will be immediately investigated by Probation Department Peace Officers with the assistance of a variety of county experts, with findings sent to ten different county and state agencies. Any or all of the contributing investigative agencies noted in Procedure 3-1-106, Section III, Subsection D, may be invited to the post incident medical and operational review. SSA Response: Agrees with finding. Response Recommendations 7.1 - 7.3 CDR timeliness: Orange County agencies that conduct CDRs should consider holding 7.1 them within a defined, reasonable time after each death, rather than on a periodic basis. Probation Response: The recommendation has been implemented. See Procedure Item 3-1-106, Section IV, Subsection C. The California Government Code Section 12525 and Probation Department Procedure Item 3-1-106 require: "A report in writing be submitted to the California Attorney General within ten days after a death in custody, all facts in the possession of the law enforcement agency in charge of the correctional facility concerning the death will be forwarded to the Attorney General's office". In summation, the Orange County Probation Department reviews any death in custody immediately and findings regarding their investigation are submitted to a variety of county agencies and the California Attorney General's office within ten days. SSA Response: The recommendation will not be implemented because it is not reasonable. SSA currently conducts quarterly Child Fatality Reviews. Conducting the reviews on a quarterly basis allows SSA to gather pertinent records and conduct a thorough review. CDR oversight: Probation should broaden representation in its review by including the 7.2 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. Response: The recommendation has been implemented. Orange County Probation Department Procedure 3-1-106, Section III - Notification Process, Subsection D, number 5: "The Chairman of the Juvenile Justice Commission will be notified by telephone immediately with follow-up in writing within 24 hours of any death in custody". In summation, members of the Juvenile Justice Commission will be invited to participate in the post incident medical and operational review required by Department procedure. SSA Response: The recommendation will not be implemented because it is not reasonable. SSA is not authorized to disclose child fatality information beyond the JJC. SSA does not have the authority to share information beyond Juvenile Court Miscellaneous Order 528.6, which is driven by law. Where necessary, SSA has the ability to work with the Raise Foundation, which is Orange County's official Child Abuse Prevention Council, or other community and county agencies on educating the community such as public service announcements. CDR membership: The Probation Department should broaden representation in its 7.2 review 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 additionally community child welfare organizations. Probation Response: The recommendation has been implemented. See Procedure Item 3-1-106, Section IV, Subsection C. Also note, Government Code Section 12525 (Written Notice of Death to Attorney General) declares this report and information therein contained will be considered public record within the meaning of Subdivision (d) of Section 6252 of the California Public - - - - - - - - - - - - - - - - - - - - Records Act (Chapter 3.5 (commencing with Section 6250) of Division 7 of Title 1), and are open to public inspection pursuant to Sections 6253, 6256, and 6257. Further, this code section notes that Section 6258 of the Public Records Act reports that "Nothing in this section shall permit the disclosure of confidential medical information that may be submitted to the Attorney General's office, nor would it allow case file information from the deceased minor, ward of a County Juvenile Court to be disclosed". In summation, a variety of officials from several public agencies within Orange County will be invited to attend the post incident medical and operational review. However, members of the public shall not be invited to this review as prescribed by exceptions in the California Public Records Act noted above. SSA Response: The recommendation will not be implemented because it is not reasonable. Juvenile Court Miscellaneous Order 528.6 authorizes the JJC to participate on CFRs and collaboratively review any dependent child fatality. Juvenile Court Miscellaneous Order 528.6 does not authorize SSA to disclose CFR information beyond the JJC. In addition, SSA is limited in regards to disclosure by Welfare and Institutions Code (WIC) 10850. All child deaths, including those reviewed by the CFR, are reviewed by OCCDRT.