The family of a boy who died of multiple skull fractures had been reported 25 times to the Department of Children and Family Services and the mother had a known history of methamphetamine use. In other families, children died within months or even one day after a social worker's last visit.
The records, which included previously confidential family services and police reports, medical charts and other documents, were obtained by The Times through a California Public Records Act request and provide the first comprehensive snapshot of child fatalities countywide.
A new state law that took effect last year loosened the confidentiality requirements that had kept most such information from public view.
All told, the records show, 32 children in the county died in 2008 from abuse and neglect, including physical assault, drowning and malnourishment. Eighteen of the children were in families that had never been in contact with the family services agency.
But the other 14 families should have been well-known to child welfare officials, based on previous referrals and investigations. For whatever reasons, many of the earlier allegations were not substantiated.
In 10 of those cases, the agency has launched investigations that will probably result in discipline against social workers, agency officials said.
"These are shocking cases," said county Supervisor Gloria Molina, who contends that disciplinary and training procedures need to be dramatically improved in the department. "The biggest problem is that no lessons are learned."
Agency officials say they lack adequate resources to handle daunting caseloads.
The heavily redacted files paint a horrific picture of the circumstances in which the children died. Among the cases:
* A 1-year-old girl who was left alone with her mother last March, despite a court order requiring monitored visits. The girl had fallen down the stairs and hit her head, her mother told authorities, explaining that she gave the girl an ice pack, put her to bed and went back to doing the laundry.
Only three hours later, when the child's grandmother returned, did the family realize that she was unconscious. Doctors found the scenario described by the mother as "highly unlikely," concluding the girl had died of blunt force trauma "consistent with being thrown or slammed against a hard surface."
Child welfare records show the mother had history of neglect.
* Another 1-year-old girl who died May 8 after a babysitter allegedly punished her for jumping on the bed. The sitter allegedly knocked the girl's feet out from under her and slammed her head against a dresser, according to police.
Family Services had received 11 complaints to the child abuse hotline related to the baby's family. One call occurred four months before the child's death, when her 18-year-old mother was arrested for petty theft.
Police at the time discovered extensive "unexplained injuries" on the infant, including "dirty and pink eyes" and rashes on her buttocks that were "almost bleeding."
Still, social workers determined that the allegation of general neglect was "inconclusive." The child remained with her mother after a social worker overruled a computer-generated recommendation that stronger action be taken.
* An 18-month-old boy who was found breathing but unconscious last May. His mother's boyfriend told them that the child had choked on a penny. When patting the boy's back didn't dislodge it, the man told medics and a sheriff's deputy, he tried to perform the Heimlich maneuver on him.
At the hospital, however, tests revealed that the boy had suffered hemorrhaging on the right side of his brain, an injury that was "indicative of shaken baby syndrome," records show. He was declared brain-dead two days later. Caseworkers had previously substantiated allegations of emotional abuse and "caretaker absence."
* A 2-year-old Pomona girl died May 19 as the result of "severe nutritional neglect," according to an autopsy report. She weighed only 18 pounds, 7 ounces, comparable to a 5-month-old.
Injuries on her body included scabbed toes, wounds on her arms and legs and a contusion on her forehead, the report said.
Earlier, police records state, she had been removed from her parents and placed in foster care, where she grew normally before being returned to them in the summer of 2007. She later was frequently visited by a child social worker and died just two months after the last visit.
* A 2-year-old girl who died on Sept. 20 after 12 days in a coma. Her mother's boyfriend reportedly shook and dropped her, according to a report filed with the California Health and Welfare Agency.
The baby's family was the subject of eight previous calls to the child abuse hotline. All eight complaints were determined to be "inconclusive" or "unfounded."
Records show that social workers did not follow up on inconsistencies in the family's explanations for previous burn marks on the child's arms, nose and face.
Family Services investigators also failed to take note of the mother's developmental disability, which might have impaired her ability to follow a "safety plan" that allowed her to retain the child.
* An 18-month-old who went into full cardiac arrest while en route to the hospital in an ambulance. A doctor who examined him there suspected abuse when he found bruising to the back of the child's head.
Two months earlier, another doctor had found bruising on the child's ear, cheek and buttocks. His mother had told the doctor that she "had an issue with alcohol" and suspected that her son was being abused at her boyfriend's house, after she fell asleep while drinking. That allegation was deemed inconclusive.
Until the investigations of the 10 cases are resolved, all workers involved have been placed in "desk jobs," said Trish Ploehn, director of the family services department.
Ploehn acknowledged that the county's review of child-death cases has been insufficient in recent years. The department did not have enough staff to review the actions of the social workers promptly.
There is supposed to be an independent monitor to identify systemic problems in the department, but that position has been left vacant by county supervisors for more than a year.
Ploehn said the department needs a better computer system for child social workers to help them access vital information held by other departments. For instance, a social worker has no way of knowing automatically whether a child has a history of being treated at a county hospital for unexplained injuries, or if a parent is receiving county mental health services for a disorder that might impair parenting.
The department has previously come under withering criticism for similar cases, but the deaths always came to the attention of the public and the Board of Supervisors one by one, and resulting reforms did not always take hold.
Supervisor Michael D. Antonovich will call today for an investigation of the 14 deaths, as well as enhanced accountability measures and information-sharing across county agencies.
"This shocking report reveals very serious procedural errors and a lack of accountability that has resulted in tragedy," he said in a press release.
Times staff writer Jason Felch contributed to this reporter.