Parental neglect contributed to the previously unreported deaths of three Santa Clara County children in 2022, even after repeated referrals urged the county’s child welfare agency to intervene and ensure their safety, according to a newly released report that raises fresh questions about longstanding failures at the troubled department now under new leadership.
In each case, social workers closed repeated referrals as unfounded or inconclusive, referred parents to voluntary services they never completed or took no further action until after a child died, according to the report issued by the county’s Child Death Review Team and led by the chief medical examiner.
In one of the cases reviewed, parents were later charged with felony child endangerment. In another, they ultimately lost custody of their surviving children. The cases have come to light because the Child Death Review Team said it “performed a deeper dive” into them, revealing more detail about the circumstances than previous reports.
The Child Death Review Team findings represent the latest blow to an agency that has faced intense scrutiny since the 2023 fentanyl poisoning death of baby Phoenix Castro. Despite dire warnings from social workers, the department sent the newborn home with her drug-addicted father, a decision that ultimately revealed agency policies more focused on keeping families together than protecting children. Her mother later died of an overdose, and her father has been charged with murder.
Extensive reporting by The Mercury News, along with investigations by the state Department of Social Services, previously found that beginning in 2021, the agency’s new family preservation policies led to a dramatic reduction in the number of children being removed from their homes by the courts, and instead a new emphasis on keeping them with their parents who were supposed to take classes to improve their parenting skills. Because those services were voluntary, however, parents often skipped or refused the services, and faced little consequence from the child welfare department. The agency’s former director, Damion Wright, resigned in December 2024. Since then, the department has embarked on a sweeping reform effort.
The agency, now led by Wendy Kinnear-Rausch, said it has implemented numerous changes since 2023 aimed at improving child safety.
“Those changes included implementing each and every recommendation from the recently released 2021-2023” report, the county said in a statement. “We remain committed to continuous efforts in every domain to keep children safe.”
Those recommendations included that when parents fail to engage in voluntary services “action be taken to ensure the protection of the children from ongoing abuse or neglect,” and that the child welfare agency provide to the Child Death Review team comprehensive fatality reviews on every case with a history of abuse or neglect referrals.
Since reforms began in late 2023, the number of children removed from their homes has since dramatically increased, returning now to earlier levels, according to county data.
But Santa Clara County Supervisor Sylvia Arenas, a former child welfare professional and the first county official to call publicly for an overhaul of the department, said there is still much work to be done. Many reforms have focused appropriately on infants and very young children, such as increasing interventions when babies are born with drugs in their systems, she said. But she believes that neglect cases — particularly involving older children — remain under-addressed.
“I don’t know that we are there yet for the older children, especially those children who are suffering from neglect or who are developmentally delayed or disabled,” Arenas said. “We haven’t really put them at the center of our focus and discussion. I think they merit that.”
The Child Death Review Team acknowledged that the department has already acted on many of its recommendations, praising its “steadfast participation, its transparency, and robust discussion.” Still, Arenas said neglect cases in particular are challenging for social services agencies to handle.
“Neglect is so silent,” she said. “Neglect doesn’t have a bruise to show for itself and so it’s harder to substantiate and harder for neighbors and friends and teachers to report.”
The team’s previous report, which examined child deaths from 2019 and 2020, identified eight deaths linked to neglect but did not clearly indicate whether those children had been the subject of prior child welfare intervention. The new report, covering 2021 through 2023, identified 12 child deaths associated with neglect and pointed out “an increasing trend of child deaths occurring in dysfunctional families.”
The latest findings also concluded that most child deaths were preventable and that isolation and stress during the COVID-19 pandemic were contributing factors in several suicides and drug overdoses.
The report warned that neglect is often minimized within the child welfare system, where it can be conflated with poverty and social workers may be reluctant to penalize poor or minority parents who are juggling multiple jobs.
California law can further complicate intervention, the report noted, requiring mandatory reporters to show that neglect “is not the result of a parent’s economic disadvantage,” which raises the bar for action by social workers.
The report cited a 2013 study finding that “children referred for physical abuse faced a significantly lower risk of unintentional fatal injury than children referred for neglect.”
“That’s kind of counterintuitive,” that neglect could be a stronger harbinger for fatality than physical abuse, Arenas said. However, because neglect is more insidious and “when you don’t interrupt and when you don’t intervene, these cases get to this point where the neglect eventually leads to death.”
A severely autistic 17-year-old boy died of COVID-19 in his bed while his mother ran an errand. Over the previous decade, the county had received seven referrals alleging abuse or neglect, including one just three months before his death. All but one allegation was deemed unfounded or inconclusive.
“The parents were referred to voluntary services on multiple occasions,” the report said, “with no evidence that the parents ever successfully engaged in such services.” Only after the boy’s death were allegations involving his siblings substantiated. They were taken into protective custody.
A 16-year-old girl died of a fentanyl overdose while staying with a friend at a board-and-care home. Social workers had engaged with with her family five times over the previous decade following reports of abuse and neglect. Because none were substantiated, no services were offered. After her death, a new maltreatment report involving a surviving sibling was also deemed unfounded, and the child was determined to be safe.
A 9-year-old boy drowned after climbing a fence with his brother into a neighboring apartment complex pool. His autism and other health conditions were considered contributing factors. The county had engaged with the family three times before his death, including over reports of suspicious injuries. Each time, the child was deemed safe. After his death, the parents were charged with child endangerment.
The Child Death Review Team said it will continue monitoring the department’s progress, particularly whether it follows up in every case where parents are offered voluntary services.
A spokesperson for Chief Medical Examiner Dr. Michelle Jorden, who chairs the Child Death Review Team, said she was unavailable for additional comment.
Steve Baron, a child welfare expert and member of the county’s Child Abuse Prevention Council, said social workers face enormous challenges navigating complex family dynamics. He emphasized he was speaking in a personal capacity, not on behalf of the council.
“It’s not an easy issue,” Baron said. “We don’t want to look back at any child death and say, you know, we should have done this or that and we didn’t. We don’t want to miss opportunities to help families and children early on, and not wait till after the third, fourth or fifth referral for suspected abuse or neglect.”
A 19-year-old former foster child in Santa Clara County, whose experience was detailed in an earlier Mercury News investigation into the county’s unlicensed group homes that were the scenes of numerous runaways and assaults, said the report’s findings were unsurprising.
The woman, Destiny, said social workers repeatedly visited her childhood home following reports of abuse but concluded the allegations were unsubstantiated and left her in her mother’s care. That outcome, she said, reinforced her mother’s belief that nothing was wrong.
“Because they were not conclusive, she didn’t really care,” said Destiny, who asked that her last name not be used to protect her privacy. “I was scared to go home a lot. It definitely made sense to why my life turned out the way it did now.”
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