Abstract
In this article we describe how singularly disturbing cases of child maltreatment propelled public child welfare reform in one large northeastern state in the United States. This case analysis demonstrates how these horrific cases set in motion a dynamic that we term the social outrage routinization process and illustrates the key roles played by the media, moral entrepreneurs, the courts and Child Protective Services (CPS) workforce in moving the process forward. The substantial trauma to the CPS workforce is considered as a consequence of the zero tolerance, infinite jeopardy, and punctuated equilibria mechanisms of the routinization process. The implications of this process for CPS policy and research on child maltreatment deaths are discussed.