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Board accepts Child Death Review Team report, directs audits and community review
Summary
The Board of Supervisors unanimously accepted the Child Death Review Team's 2021'023 report, directing county staff to set up ongoing audits, a community roundtable and follow-ups with state reviewers. Officials emphasized prevention strategies tied to substance use, unsafe infant sleep and mental-health risks.
The Santa Clara County Board of Supervisors on Monday voted 5-0 to accept the Child Death Review Team's report covering 2021'023 and to direct a package of follow-up actions aimed at preventing future fatalities.
The report, prepared jointly by the county's Public Health Department and the medical examiner's office, tallied patterns contributing to child deaths and recommended expanded prevention work, including audits of child protection decisions, creation of an independent oversight presence to review high-risk case decisions, and a community roundtable to coordinate cross-agency responses.
Dr. Sara Rudman, director of public health, told supervisors the review looks beyond individual cases to social and structural factors. "Child mortality is complicated, and we have to look to historical disparities and systems of historic racism," she said, urging investments in community-driven prevention and supports for families.
Medical examiner staff described the CDRT's process for deep case reviews and its finding that higher counts of adverse childhood experiences (ACEs) were associated with risks such as unintentional injury, overdose and homicide. "Our mission is to learn why children die, and to prevent those deaths," Dr. Jordan, the county medical examiner, told the board.
Supervisor Sylvia Arenas, who sponsored the motion to accept the report, stressed the need to convert findings into operational steps and to avoid a cycle of reactive policy changes. The board asked county executive staff to return with specific plans, including an external audit mechanism, an updated corrective-action timeline with CDSS for cases now under state review, and a community advisory process to bring lived experience into prevention planning.
County Executive James Williams said the county would map recommendations to budget and staffing implications and pursue state-level partners. He also warned of looming state and federal funding risks that complicate local implementation.
The board requested quarterly reporting on progress and directed administration to return in August with options for the independent review office and models for the community roundtable.
The CDRT meeting and the board's discussion included a large public comment period in which family members, child advocates and county social workers described workforce strain and urged faster action. The board accepted the report and its recommended follow-up steps by unanimous vote.
The board's vote directs staff to prepare implementation options and to bring a timeline and budget implications back to the board in August.
