The National Center for Fatality Review and Prevention

Program Description

Administration
Under an Executive Order of Governor Stephen Merrill in 1996, New Hampshire began systematically reviewing the preventable deaths of New Hampshire children to identify risks and provide feasible recommendations for opportunities for prevention. This Executive Order has guided the work of the Child Fatality Review Committee (CFRC) for more than 20 years. The CFRC was then re-established in 2019 and put into statute with support from Governor Chris Sununu. The Committee is comprised of representatives from medical, law enforcement, judicial, legal, victim services, public health, mental health, child protection, and education (RSA 132:41).

Teams
The CFRC has two co-chairs, an Executive Committee, and two formal subcommittees on Sudden Unexpected Infant Deaths (SUID) and Sudden Death in the Young (SDY).

State Team:
The CFRC has co-chairs selected by the full body and has an Executive Committee. Currently, the Committee has a dual structure consisting of:

The CFRC’s Full Committee charge is to identify factors associated with preventable deaths and to make recommendations for system changes to improve services for children and adolescents through age 21. The goal is not to investigate or adjudicate, but to learn from the circumstances of each case to take action to prevent future deaths. Recommendations focus on community-based prevention and should lead to effective multidisciplinary strategies to keep children healthy, safe, and protected.

The CFRC Executive Committee develops protocols and selects child deaths for review based on data trends in the previous annual report and available information from the Office of the Chief Medical Examiner (OCME) of the New Hampshire Department of Justice. This Committee uses the expertise and knowledge of CFRC members to discuss and answer the following questions after reviewing selected child deaths:

1. What changes could have prevented the deaths?
2. Are changes necessary to prevent future deaths?

Reviews
The New Hampshire CFRC reviews preventable child deaths from age one through twenty-one. The CFRC is not obligated to review all child deaths. They do not review cases that have criminal or civil matters pending, or if they are in court. Case reviews are conducted retrospectively. Reviews are held 6 times per year. Pursuant to RSA 91-A: 3, II (c) and RSA 91-A: 5, IV, the CFRC holds a non-public session during the case review process. CFRC members sign a confidentiality agreement stating they will not share any case-specific information or the nature of any discussion that took place during the non-public session with anyone that is not present at the case review. This ensures that the information in each review remains confidential.

Purpose
The purpose of the New Hampshire CFRC is prevention of child deaths in NH.

Data
New Hampshire CFRC has access to state vital statistics. Vital statistics are used to aid the reviews.

Annual Report
New Hampshire produces an annual report based on the previous state fiscal year.

Prevention Initiatives
CFRC findings have influenced policy changes. Statewide examples include: the support of the expansion of SUID/SDY subcommittee; the encouragement of medical providers to offer up-to-date product safety information to new parents; the review of model legislation pertaining to thrift store product safety; development of bereavement packets to be given to families; and many more. An example of how CDR findings have resulted in prevention activities in the use of the media to promote education and prevention efforts in accidental deaths. Additional initiatives are highlighted in the NH CFRC annual reports.

Protocols
New Hampshire has a review protocol in place.

Training
The New Hampshire CFRC provides new member orientation information that includes but is not limited to; the purpose, history, legislation, objectives, confidentiality and roles and responsibilities of members.

Last Updated: March 2025