IN 2008, AMY CASTILLO’S three children were drowned by their father in a tragic case that spotlighted the failure of Montgomery County’s court system to heed a mother’s plea to limit access by her estranged and mentally troubled husband.

Four years later, another child, Prince McLeod Rams, died — allegedly drowned by his father for insurance money — after another judge in Montgomery Circuit Court granted unsupervised visits despite a mother’s warnings.

Some say that such cases, while terrible beyond description, are so rare they prove the strength of a system that handles thousands of complex, emotional situations each year. In fact, only by viewing these cases, no matter how infrequent, as preventable can families be better protected.

We have written about the Oct. 21 death of 15-month-old Prince Rams McLeod following the fourth unsupervised visit at his father’s Manassas home. We’ve criticized how Montgomery and Prince William County authorities dealt with Prince’s father, Joaquin S. Rams, who is now charged with first-degree murder in the boy’s death. (He says he is innocent.)

Are there reforms that could lessen the chance of tragedy? Family law experts, academic and professional, told us that there should be a rigorous, external examination of every case in which a death occurs. Review by the court’s administrative judge, as in Prince’s case, is insufficient. Maryland court officials, who don’t even keep track of deaths, should assemble experts from various disciplines — law enforcement, mental health, the judiciary — to determine if proper action was taken, if warning signals were missed, and if new procedures or laws are needed. The aim would be not to assess blame but to identify systemic weaknesses and foster best practices.

Montgomery lags other Maryland jurisdictions in a number of ways, including the absence of a center where supervised visits by non-custodial parents can take place. Montgomery used to have such a center, but the owner of the company that operated it died and funding dried up. Parents now hire private agencies at high hourly rates, and the visits occur in less than ideal settings. Would trained social workers like those employed in Baltimore’s centers have been able to provide more useful information than the retired police officer who supervised the initial visits between Prince and his father? In addition, Baltimore’s system of using staff psychologists to perform mental health evaluations seems preferable to the process that allowed Mr. Rams to pick a psychologist who gave Mr. Rams a clean bill of mental health that played a role in the court’s decision.

Perhaps most critical is whether it makes sense for Maryland to continue to rotate judges in and out of family court. Family law constitutes about 40 percent of the state’s trial court filings, but it is generally seen as less desirable than criminal or tort law. The cases are hard, the work is grinding and the burden on judges (deciding outcomes without benefit of juries) is heavy. Perhaps that argues for a permanent cadre of jurists trained in family law and committed to the importance of helping families even as they are falling apart.