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Like other counties, Kern Public Health skips report on child deaths, citing lack of resources

The Bakersfield Californian - 11/13/2022

Nov. 13—Moon-shaped bruises marred a 5-year-old boy's backside from "owies," he told a social worker, according to a case report written by a Kern County Sheriff's Office deputy from an interview between the child and a social worker.

The boy marked three X's on a body diagram using a dark red crayon to show where he said his father, Mister Bailey, struck him. With a green crayon and a black crayon, the boy drew a belt in the page's corner, according to the deputy's report, which was filed in Kern County Superior Court.

Bailey flipped him upside down and used that belt to "whoop him," the boy said, according to the reports filed in court. He closed his fist to demonstrate how Bailey punched him in the face about 10 times, according to the documents. Sabrina Martinez, the boy's mother, also beat his face around 19 times, the child told the social worker.

(The boy) "does not know why his mom ... hits him in the face, and he does not like being hit in the face," the deputy wrote in his report.

Then the social worker told the 5-year-old about blood at his Tehachapi house, where he lived with his 3-month-old brother and a sister, the reports said. She asked where it came from, the reports state.

"My, my brother's dead," the boy replied, according to the reports.

Bailey and Martinez were charged in the 3-month-old's 2020 death and several child cruelty charges. They are scheduled for a pre-preliminary hearing in January to determine if the case will proceed to a preliminary hearing.

Child Death Review Team

Dozens of children die every year in Kern County, and if the coroner refers a case to what's know as the Child Death Review Team, then the incident is studied by local first responder agencies and researchers to determine what went wrong.

In past years, this team released an annual public report about its findings. Collecting and discussing data about child fatalities are critical for agencies to thoroughly understand the causes behind deaths, local trends and preventing future mistreatment, according to child advocates.

But the Kern County Public Health Services Department, which is tasked with creating and compiling the report, hasn't put one together since its 2019 release that looked at 2018 deaths. The number of child fatalities in Kern is higher than California's average, according to data compiled by, an online database for children's health.

The death of the 3-month-old would have been examined in this report.

"Without some of that information, it's really difficult to dig in to know" how to make changes to reduce fatalities, said Jessica Haspel, the associate director of child welfare with Children Now, a nonpartisan nonprofit focused on elevating children's issues through advocacy.

Haspel spoke generally about child death review teams throughout California and not about Kern County's policies specifically. She added it's difficult to know the pandemic's effect on child abuse throughout the state without data.

"These child death review teams are the glue that holds everything together because they are interdisciplinary," said Dr. Jeoffry Gordon, a retired family physician who advocates for child welfare.

County public health's response

Public Health spokeswoman Michelle Corson wrote in a Thursday email the COVID-19 pandemic "significantly impacted" operations of all participating Child Death Review Team agencies.

Corson wrote in a March email that all staff were diverted to "COVID-19 duties" shortly after the pandemic began.

"While there hasn't been a report released in the last (two) years, throughout the pandemic (Child Death Review Team) meetings continued and cases were reviewed," Corson continued in her email Thursday.

Corson added in that email the staff is developing reports from the "impacted times" and should present them to the county's Board of Supervisors "within the next couple of months." The last report was issued in December 2019.

Inquiries into similar reports by child death review teams in other California counties' shows Kern Public Health isn't alone in forgoing public releases.

Tulare County doesn't have a child death review team and Marin County does "not issue public reports" but does track all child deaths, according to the counties' respective spokeswomen. Kings County hasn't issued a child death review team report in "a while" because of COVID-19, said Everado Legaspi, a program manager with the Kings County Public Health Department.

Legaspi added the department is looking into reconvening a child death review team, but it is "a pretty small department." He also couldn't find a child death review team report on his "servers."

Santa Clara County released its latest child death review report in 2020 about data from 2018. Los Angeles County released its latest report in 2021.

Corson wrote that Kern Public Health addresses preventing child deaths by launching initiatives such as the water watchers campaign to teach parents about watching children playing in and around pools, free and accessible hands-only CPR training and a "safe baby, safe child" conference, which happened in October.

That conference focused on health education regarding sudden infant death syndrome, adolescent suicide and fentanyl use, she added.

Tom Corson, head of the Kern County Network for Children, did not respond to a request for comment. The Kern County Network for Children advocates for kids, and is a member of the Child Death Review Team. Other team members include the Bakersfield Police Department, the Kern County coroner's office, the Kern County District Attorney's Office, Bakersfield Memorial Hospital, Kern County Sheriff's Office, the Kern County Department of Human Services and others.

'Exchange ideas, thoughts'

The child death review team was created in the early 1980s, and participants are not mandated to convene under the state law that outlines the team's creation.

A broad range of experts, such as forensic pathologists, pediatricians who have experience dealing with child abuse cases and criminologists, should collaborate and release reports, according to California law. State agencies should track local data on child deaths, according to the law.

"They each bring a piece to solve the puzzle," Colleen Friend, director of the Child Abuse and Family Violence Institute at Cal State Los Angeles, said of an interagency effort. "... And often these things are very complicated. Often, a coroner or a DA might bring something that a protective service worker would not."

Past Kern County reports parsed out deaths as preventable or accidental, and whether the death was a homicide. They laid out solutions for separate agencies and social workers to prevent child deaths.

The intent was to create a "body of information" to prevent child deaths, the law said.

Ruby Guillen, who sits on a citizen review panel aiming to prevent child abuse and critical incidents and is part of Los Angeles' version of the child death review team, said a typical meeting in L.A. might include inviting the people investigating a child death and trying to figure out what happened. Guillen is part of the Inter-Agency Council on Child Abuse and Neglect, an independent body that develops and coordinates services for the prevention, identification and treatment of child abuse in L.A. County.

The purpose isn't to chastise, or to make a person feel stupid, she said. She's learned a red flag for child abuse could be broken bones, and suspicions shouldn't be disregarded because those injuries could lead to death.

"If you want to reduce fatalities, we need to partner and we need to engage," Guillen said. "We need to exchange ideas, thoughts. Again, it's all about learning. You have to only learn by knowledge."

Necessary reforms

Friend wasn't surprised when told about Kern Public Health and others skipping out on the child death review team reports. She said a lack of money could contribute to counties failing to compile them.

Child death review teams relied on the Legislature providing dollars to establish these processes. However, the National Center for Fatality Review & Prevention notes the state's child death review team was disbanded in 2008 when funds were taken away.

Corson, the Kern Public Health spokeswoman, said the county does not get funding for releasing its Child Death Review Team reports.

Gordon, the retired physician, added data is sparse across the state — the Department of Social Services was required to release a report detailing child fatalities, but has failed to do so since 2016. That data could shape policies from lawmakers, experts agreed.

Establishing a network of data will allow child deaths to be reduced, Gordon said. A surveillance network was created to watch births to develop new protocols about safety. California's maternal mortality rate is the lowest in the nation as a result, Gordon said.

"Nobody in the state of California can tell you how many children under 18 died at the hands of their parents or caregivers last year," Gordon said. "Period. Nobody. Nobody has access to real data."

Assembly Bill 2660, which was vetoed by Gov. Gavin Newsom in 2022, sought to make child death review teams mandatory across the state to track this information. Newsom wrote in his veto message the program was too expensive. Gordon disagreed.

"One hunded-plus kids ... die every year ... (and) it's a low priority for the state," Gordon said. "To me, it's an atrocious, horrible circumstance."

A spokesperson for Newsom's office linked to AB 2660's veto message in response to The Californian's questions about his veto and steps to reduce child deaths.

"There can be helpful, remedial efforts put in to make the system work," Gordon said. "It's not very expensive. It's just been overlooked since 2008 (when the statewide program was defunded)."

You can reach Ishani Desai at 661-395-7417. You can also follow her at @_ishanidesai on Twitter.


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