Santa Clara County Child Death Review Team 1994 & 1995

Appreciation & Dedication

We dedicate this report to Dr. J. H. Williams, pediatrician and long-time team member, who recently retired. His commitment and interest over many years have been a positive force for the county’s children.

The members of the Death Review Team would like to thank their affiliate agencies for their support. The Death Review Team also thanks Su-Lin Wilkinson, MPH, Health Planning Specialist from the Public Health Disease Control & Prevention Division, Data Management & Statistics for providing county population data and analyzing statistical significance of Death Review Team data.

The Santa Clara County Child Death Review Team

Summary Report
1994 & 1995
And Statistics 1990 - 1996

On October 25, 1995, the Santa Clara County Child Death Review Team (DRT) marked its tenth year of existence. During those years, the DRT has met monthly to review selected cases of child death, with its focus continuing to be on identifying factors in each case that may be used to improve the service systems throughout the county.

Over the years, there have been major achievements resulting from the DRT’s efforts, including such things as the implications of substance abuse for death of newborns; and efforts to acquaint both service providers and the public regarding issues that present risk to children, such as “bucket drownings,” and the pressures that sometimes lead to adolescent suicide.

Because the DRT is multidisciplinary, there is much cross-disciplinary education and networking.

The DRT has also expanded its membership through inclusion of additional representatives from certain agencies and expanded expertise from the medical and public health communities, including an accident prevention specialist, and an additional physician whose special interests include perinatal substance abuse.

In addition to cases falling within the specified criteria, the DRT has, on occasion, reviewed “high profile” cases which have presented issues related to coordination of and/or need for services not readily available in the community.

The DRT has also entered the “electronic information age” through the computerization of data presented at meetings and the accumulation of current statistics regarding such information as date, cause of death, agencies involved, and type of review done by the DRT. This effort will, it is hoped, provide a database for future comparison of trends and specific information regarding the cases reviewed.

The DRT continues to have, as its primary goal, the ongoing assessment and improvement of services within the county. In light of diminishing resources, the need for improved coordination and sharing of information among the many service providers -- both public and private -- within the Santa Clara County community is essential. We believe such continued efforts will help in the development of a services system that will better respond to individual needs and, hopefully, provide the protections needed to reduce the number of preventable child deaths, and ultimately improve services for all children.

Summary and Major Recommendations



Sudden Infant Deaths

A detailed study of SID (Sudden Infant Deaths) in Santa Clara County from January 1, 1993 through July 1, 1995 was completed by Fran Bergman, PHN, Team Coordinator; J. H. Williams, MD; and Patrick Clyne, MD. Sudden Infant Death is defined as the sudden death of an infant one year of age or younger which is unexpected by the infant’s history and where a postmortem examination fails to demonstrate an adequate cause of death. The key findings were:

Recent public education programs are changing how parents place infants for sleep. It may be that this is responsible for the decline in presumptive SID cases (i.e., 35 cases in 1994, but only 9 in the first half of 1995) during the study period. Many parents and caretakers have still not been informed of the proper sleeping positions for infants, so it is vital that educational efforts in this area be continued.

Some infants died of pneumonitis (lower respiratory tract infections) but showed no obvious signs of severe illness in the 24 hours prior to death, according to their parents. Other children showed signs of nasal congestion, fever, and otitis media. The symptoms of respiratory compromise in infants are subtle and easily missed by parents and caretakers. Health care providers need to constantly evaluate methods and types of information about both health promotion and recognition of illness.

The SID rate for infants exposed to prenatal substance abuse appears to be four to five times higher than in the general population.

The full report may be found in the Appendix.

Criminal Prosecution

The Death Review Team (DRT) has helped develop better knowledge and cooperation between law enforcement, the district attorney, the coroner, and the medical community.

The County District Attorney’s Office filed criminal charges in four (in-home) child homicide cases involving children who died of abuse or neglect in 1994-1995, and one case involving a child who died in 1982. As is typical of young child homicides, all perpetrators were parents or caretakers of the victims and all used no weapons other than their own hands. Summaries of the cases follow:

  • Case 1: A five-year-old boy was starved to death by his parents. This case was remarkable for its extensive involvement with the child protection system in a neighboring county. At one time, the child was battered with his father pleading guilty to felony child abuse. The child and his sibling were placed with grandparents, but were allowed contact with, and eventually returned (without court knowledge) to the care of their parents where the five-year-old died of starvation. The grandparents were convicted of child endangerment, and murder charges were filed against the parents, who are awaiting trial.
  • Case 2: A four-year-old girl was beaten over a period of approximately one week by her stepfather, resulting in her death. Murder charges are pending against the stepfather, and child endangerment charges are pending against the mother.
  • Case 3: A four-year-old girl was beaten to death by her stepfather. The child died of closed head injuries. The perpetrator pled guilty to a new homicide statute effective January 1, 1995 and was sentenced to 15 years to life.
  • Case 4: A two-and-a-half-year-old boy was beaten to death by his mother and/or his mother’s boyfriend. The child died of blunt force abdominal trauma. A jury found
  • Case 5: A five-month-old girl was shaken to death by her mother’s boyfriend in 1982. The cause of death was not recognized at that time. Four years later, the perpetrator beat to death the two-year-old son of another girlfriend and was convicted of murder in a neighboring county. The case was reopened in Santa Clara County in 1994, based on expanded knowledge of the shaken baby syndrome and specialized training in child abuse investigation and prosecution. Murder charges in the 1982 case are pending.

Case Finding

Of the child deaths coded as caused by abuse, almost all of the families were previously known to child protection authorities. This suggests that current reporting and case identification systems are working fairly well, although continued support for education and dissemination of information is needed to assure that community awareness and reporting continues. Because this part of the system seems to be working, we may now be able to focus more concentrated energy on some of the areas of concern, which follow.

Perinatal Drug Use

As long as six years ago, the DRT (as well as others in the community) identified a close connection between perinatal substance abuse and harm to infants, including preventable child deaths. Subsequently, a new California law (Penal Code Section 11165.13) requires that all perinatal patients be screened/assessed for substance abuse, and that appropriate treatment, support, and community services be given to help the mother, child, and family. In response to this law, the Perinatal Alcohol & Drug Use Coalition of Santa Clara County developed the county “Perinatal Substance Abuse Protocol” which was approved by the Board of Supervisors and implemented on July 26, 1994. Use of this protocol is expanding among perinatal health care providers. The DRT considers implementation as a giant step forward, and one that needs continued support.

Once high risk situations are identified, the need to develop effective, prevention-oriented services and interventions is heightened. While the county now has a clinic available to pregnant women who are drug users, clinic services are somewhat limited. For example, there are no psychiatric services available at the clinic. The DRT’s review of other programs in other areas indicates that a bigger and more comprehensive push is likely to be needed to have the better outcomes needed to meet the goals of minimizing harm to infants and preventable deaths in this population. From a cost/benefit point of view, the DRT views such an effort as not only worthwhile, but necessary.


In light of decreasing budgets, agencies and providers that deal with children have had to become more attentive to their prime mission and more task-focused. Increasingly, time for taking a good social history -- which would include information on violence in the home, drug use, individual and family histories of abuse and neglect, and other risk factors -- has diminished so that the task at hand can be done and the case closed in order for staff to move onto the never ending influx of new cases and situations. Further, many physicians and other health care professionals are reluctant to inquire about issues related to drug use and domestic violence, viewing these issues as too sensitive and not in their domain.

The use of the Perinatal Substance Abuse Protocol and the Santa Clara County Domestic Violence Protocol for Health Providers should soften the impact of agency downsizing and the trend to managed care. The DRT believes these vital protocols need to be fully utilized. Copies of the protocols may be found in the Appendix.

With dramatic changes in health care there is greater responsibility on parents and other caretakers to be able to monitor children’s health status and to respond and seek care when needed. This approach breaks down when the caretaker is not willing or able to assume such responsibility. An assessment of caretakers’ competence should be part of any health care plan.


Coordination is time consuming and, in a time of restricted budgets and program downsizing, is necessary to effectively use information. Coordination is vital to identify children who need services to keep them from harm. While we recognize the need to safeguard people’s privacy and to assure their civil rights and not be prejudicial, we have seen several cases in the past two years where care was fragmented and service providers, though well meaning, did not have the kind of historical record that would have helped them in preventing a child’s death. Efforts must be put into developing and implementing information exchanges that will assure a basic level of shared knowledge among those involved in determining the risk of harm to children and prevention of child deaths. Technology, specifically use of voice- and e-mail systems, is a beginning in facilitating more effective communication and cooperation.

Longitudinal Care

Health and welfare care have become more and more crisis focused. Cases are closed as quickly as possible when the immediate crisis has been ameliorated. Long-term provision of services is limited and, with the expectation of block grant funding, it is anticipated that even fewer resources will be available for families needing more than brief, crisis-oriented services. Unfortunately, many of the families who have contact with the child protection system are subject to relapse without some sort of continuing support. Agencies need to recognize there are limitations to the crisis intervention approach, particularly for very high-risk families. For such families, a longitudinal care approach may be more cost effective in the long run, and agency policy makers are encouraged to consider this in the allocation of resources.

New Definitions of Abuse and Neglect

Society has gradually been increasing its expectations of parents and caretakers, and some of these increased demands are codified in law. Legislation addressing the use of infant car seats and the storage of guns are two examples. Passing legislation is only a step in the process of education and changing of social norms. Additionally, people who tend to place their children at risk are often resistant to, or unaware of, prevailing social norms and efforts to modify their behavior. The DRT would like to see increased efforts to educate the population about public health issues. The use of television and radio, including ethnically-oriented media, may offer the best opportunity for this education.

Zero Tolerance

In the past two years, many school districts have adopted a Zero Tolerance Policy with regard to students who bring weapons or drugs onto school property. While we understand the issues involved and the need to keep schools safe, the policy has created some secondary problems. The DRT has reviewed the deaths of two youths who committed suicide after being expelled under Zero Tolerance rules. While these youngsters lives may have been troubled, or they may have been from families with severe problems, their acting out behavior directed at either themselves or the community needs to be considered in the enforcement of Zero Tolerance. Enforcement of Zero Tolerance should be coupled with the development of other programs directed toward adolescents, especially in light of decreases in services to adolescents, which have occurred through the dropping of status offender programs, reduction of probation services, and dropping of conduct-disordered children from mental health programs.


The DRT has developed an ongoing database regarding coroner cases of child deaths in Santa Clara County. The database currently allows the DRT to quantify all information regarding age, ethnicity, cause of death, etc. See Appendix for 1994-1995 case data and comparative tables covering previous years. These data may provide information useful in measuring the impact of changes in the Child Welfare & Health Systems. It may also allow comparison of information with state and national databases. This information is available and may be useful to county agencies in strategic program planning.


The Santa Clara County Child Death Review Team has maintained its focus on prevention of illness, injury, and death of children through constructive examination of and suggestions about ways to improve services to children and their families. It has also advanced public knowledge of child risk issues throughout its ten years of operation. It has emerged from a grassroots, somewhat tentative group into a respected and supported part of the county’s efforts to assess, improve, and stabilize services to its children. The DRT is currently facing (along with most public agencies and with the physician community) changes that may result in even more erosion of social and health care services. We have great concern regarding the trend toward downsizing of agencies and the shrinkage of resources in our community. As the community enters the era of managed care and block grant funding of public social services, we look to government to provide leadership in supporting agencies and professionals in developing strategic plans that will counterbalance the continuing diminishing of resources.


Classifications of Death

  1. Abuse: Clearly due to abuse, supported by Coroner’s reports or police or criminal investigation (e.g., homicide).
  2. Abuse Related: Death secondary to documented abuse (e.g., a death at Agnews Center several years following brain damage due to abuse; suicide in a previously abused child).
  3. Neglect: Clearly due to neglect, supported by Coroner’s reports or police or criminal investigation.
  4. Neglect Related: Death secondary to documented neglect (e.g., auto accidents or house fires where caretaker “under the influence”). This category would also include any cases of poor caretaker skills or judgment.
  5. Suspicious or Questionable: There are no specific findings of abuse or neglect, but there are such factors as:
    1. Substance use or abuse where substance exposure caused caretaker to have mental impairment.
    2. Previous unaccounted for deaths in the same family.
    3. Prior abuse or neglect of child or protective service referral.
  6. Maternal Substance Abuse: Clearly due to prenatal substance abuse supported by Coroner’s reports (e.g., cocaine intoxication, death from medical complications due to drugs).
  7. Maternal Substance Abuse Related: Death secondary to known or probable prenatal substance abuse (e.g., SIDS with known perinatal exposure to drugs).
  8. Non-Maltreatment:
    1. Natural medical death
    2. Sudden Infant Death (SID) (No known or suspected prenatal substance exposure.)
    3. Accident (This category is for accidental deaths for which there are no elements of neglect. The team recognizes that accidents do occur in even the best of families.)
    4. Suicides (No known contributing factors of child abuse or neglect.)
    5. Non-Maltreatment substance abuse related

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