Records Faulted in Girl’s Abuse Death

A grand jury report on Wednesday said a lack of communication among Orange County agencies prevented them from recognizing a pattern of abuse that led to the death of a 13-month-old Anaheim girl two years ago.

In February, the girl’s mother, Jacquelyn Starr Gutierrez, 23, was sentenced to eight years in prison for child abuse. She pleaded guilty to neglecting her daughter to the point that the baby starved to death.

But on Wednesday, the Orange County Grand Jury said lack of communication among the county Social Services Agency, the Anaheim Police Department, local hospitals and a child advocacy center resulted in missed opportunities to save Samantha Rose Gutierrez.

In the five months before her death, Samantha had been in and out of hospitals for bruises and undernourishment, and police and social workers had visited her home several times. But the overall pattern had been missed by everyone, the report said.

“There are a lot of hard-working people in these agencies,” said jury foreman Tom W. Staple, “but we feel they could do a better job of coordinating a little more with each other.”

Local clinics treated Samantha for a number of problems, including fractured bones and undernourishment starting in October 2001, the report said, but in nine out of the 10 times she received medical care, the doctors and nurses did not raise suspicions of abuse and report the case to social workers.

In one hospital visit three months before she died, doctors and nurses treating Samantha for a fractured arm noted her poor hygiene and the mother’s uncaring attitude, the report said. They called social services.

A social worker concluded that the girl was being neglected. The next day, the social worker offered the mother help with parenting classes and other resources, which she declined.

“This was the last visit by a social worker,” the report said.

The abuse also was missed by Anaheim police who visited the Gutierrez home, a converted garage shared by two families. Each of the three times they visited -- twice in October 2001 and once in January 2002 -- was after a family friend complained about child abuse, the report said.

The officers had apparently found no evidence of abuse and had not referred the incidents to social services, the report said.

On Wednesday, Anaheim Police Chief John Welter agreed with the grand jury finding that officers need more training to recognize child abuse.

The panel also urged the Social Services Agency to keep better records of calls to its child abuse hotline.

Before Samantha’s death, social workers screened the calls and recorded only those they thought should get priority.

Now all calls are logged.

Eli Home, a child advocacy center, said it called the hotline two months before Samantha’s death after hearing allegations of abuse from a housemate. The Social Services Agency said it had no record of the call.