Quick Take
Four children – including a Santa Cruz toddler who died of a possible fentanyl overdose – have suffered tragic, violent and unnecessary deaths in the Bay Area in the past two years, writes retired Santa Cruz family physician Jeoffry B. Gordon. He believes our child welfare system failed these kids and that we need to rethink policies, particularly reforms prioritizing family preservation. He is also appalled at the lack of accountability and transparency in Santa Cruz County’s Child Protective Services and calls on the board of supervisors to take action.
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There have been four preventable, avoidable, tragic cases of young children who were murdered within the past two years in Bay Area counties. Yes, murdered: While the children died of abuse or neglect by their families legally, the deaths are murders.
Three of the recent deaths – including one of a Santa Cruz toddler – involved fentanyl, the drug our retiring sheriff, Jim Hart, says makes drugs like heroin, cocaine and methamphetamine “look like baby drugs.”
The cases are grim. Two infants were born with drugs in their systems in Santa Clara County and later died of fentanyl overdoses. A Contra Costa County toddler, also born addicted, died after being brutally beaten. And here in Santa Cruz County, the death of a toddler is being investigated as a fentanyl overdose. Family and friends said they reported the family to Santa Cruz Child Protective Services (CPS) numerous times. The father, who died of an overdose, had past abuse charges against him.
Our child welfare systems failed these kids.
All these children were put at risk and all died because the systems designed to protect them were not paying appropriate attention. This is happening at a time when well-meaning people and agencies across the country, state and even here locally are reflecting on the current biases and deficiencies of the child welfare system and trying to improve its capacity and functioning.
As a family doctor, I am intimately aware of the massive, often lifelong harms inflicted on children by abuse or neglect, usually by the people they most depend upon for nurture and safety. As a volunteer member of California’s Citizen Review Panel for critical incidents (child homicides due to abuse or neglect), I learned that half of these tragic deaths are of infants less than a year old. I have spent years advocating for more safeguards for kids like these.
One advocated policy reform counties have implemented is to promote “family preservation” aiming to keep families together. The idea is kids are best off with their biological parents. This might have contributed to CPS returning these four at-risk kids to the care of noncompliant substance-abusing parents, with fatal results.
Removing at-risk children from dysfunctional families naturally comes with possible harms. These include the emotional impact of confusion, grief and trauma caused by separation from family. Then there are the possible harms of foster care, including abuse and neglect in foster care, frequent disruptive moves, and poor management of trauma and over-medication. The most severely traumatized children are the hardest to manage, because they often act out.
In my opinion, the misguided reform efforts contributed to these tragedies.
A quick look at the numbers illuminates my point. Each year in California, a minimum of 60,000 children have substantiated cases of significant child abuse or neglect. There are about 60,000 children in foster care in California at any point in time, and 100 children enter the foster care system for the first time in California every day. Each year 120 to 160 California children are killed by abuse or neglect, usually by their parents or guardians.
That is far too many.
I wish we knew more details about CPS protection of children and families in our own community. The 2023-24 Santa Cruz County civil grand jury tried to assess the policies and procedures allowing family preservation or when a child should be removed. It sadly came up empty – not because there is nothing there, but because, “there is no data regarding the outcome of [CPS] services.”
The report also found that “the current law tends to lean towards equity which leads to some staff feeling that they should ‘over calibrate’ toward birth families. The (CPS) staff strongly agrees that family reunification is of the highest priority unless there is a danger to the child.”
In addition, the public cannot get insight into the “volume of services.” That means we don’t even know how many children and teens are in the system or what happened to them. Finally, the grand jury found the CPS formal complaint process lacks transparency and is ineffective, resulting in a lack of accountability.
In this context, we cannot even be certain that CPS is paying enough attention to child safety.
The county board of supervisors should take this seriously and should convene a panel of child abuse experts, not to study, but to institute practical and common sense reforms of Child Protective Services.
Scientists are beginning to understand the extensive biophysiological harms of child abuse and neglect. Abused children are much more likely to suffer chronic physical and mental diseases, alcoholism, substance abuse and social pathologies such as homelessness, criminality and mass shootings. This is motivating a broad interest in preventing and treating child maltreatment. Few people, even policymakers in health agencies, are aware that each year in the United States as many children die from abuse and neglect as from childhood cancers.
To be fair, I know the agencies and many staff members are working hard and doing their best, and that their many successes go unheralded. Wise judgment for assessment, intervention, appropriate care and therapies is difficult, stressful and resource-intensive, whether by official child welfare agencies, courts, community agencies or individual clinicians.
Still, we must do better, and these four tragedies prove that child safety must come first.
At the state level, a Child Welfare Council task force took on these big questions last year and made numerous recommendations to promote more caring child welfare services, less bias, and family preservation. This was encouraging, but also was misdirected because it did not put child safety first, and in its eagerness to escape bureaucratic child welfare agencies, it also did not recognize or evaluate the shortage, understaffing and waitlist delays of community resources in most California counties.
We must recognize that innovative official policies like “family preservation,” and increasing dependency on overstretched “community supports,” while well-intentioned, can put children at greater risk.
In Santa Clara County, the board of supervisors has had two hearings in the past 12 months where supervisors discussed the toddler deaths. No changes have occurred yet, but improvements are underway. At least they are paying attention.
I wish I could say the same about our county.
We are fortunate we don’t have a large caseload of children under CPS supervision. But we know far too little about the kids we do have. That is why the board of supervisors needs to step in. It should create a panel of child abuse experts not just to study, but to take action to initiate needed reforms to the system. And it should demand more information from CPS.
Not knowing is not acceptable.
We can and must do better. We can’t let more kids remain unprotected.
Jeoffry B. Gordon had a family medicine practice in Santa Cruz for 35 years until his retirement 17 years ago. He spent four years in a federally qualified health center treating the unhoused. He is currently a member of the California Citizens Review Panel for Critical Incidents (fatalities due to child abuse). He served as a medical bioethics consultant at Sharp Memorial Hospital in San Diego for 10 years. He spent eight years on the Medical Board of California, which licenses and disciplines physicians. Gordon lives in Santa Cruz and is a widower with two daughters and four grandchildren.