The National Center for Fatality Review and Prevention

Program Description

Administration

North Carolina’s Child Fatality Prevention System (CFP System) was originally established in 1991 by state law. Legislation that passed in 2023 restructured the system, provided additional funding, and expanded system responsibilities. Most of the changes required by the 2023 legislation became effective on July 1, 2025.

The CFP System is governed by statutes in Article 14 of the North Carolina Juvenile Code (N.C.G.S. 7B-1400 through 7B-1414), and N.C.G.S. 143B-150.25 through 143B-150.27.

The system has four primary components:

1. Local Child Fatality Review Teams (Local Teams)

Local Teams operate in all 100 counties, bringing together at least 15 multidisciplinary members, as outlined by statute. Local Teams have been in existence since 1991, though their structure and responsibilities have evolved over time.   

• State Office of Child Fatality Prevention (“State Office”)

Located in the NC Division of Public Health within the NC Department of Health and Human Services (DHHS), the State Office coordinates and supports the statewide Child Fatality Prevention System. Staff in this office provide training, guidance, and technical assistance to 100 Local Teams, with specialized support for cases involving child maltreatment. The State Office also manages, analyzes, and reports aggregate information learned from Local Team reviews and other data sources, and communicates aggregate findings and recommendations of Local Teams to various State organizations, including the Child Fatality Task Force. The State Office was established by 2023 legislation and is funded through state appropriations and, when fully staffed, includes up to six positions.

• North Carolina Child Fatality Task Force (Task Force)

The Task Force has 36 members: state agency leaders, ten state legislators, community leaders, and experts in child health & safety.  It receives reports and data from the State Office and others, develops recommendations, and submits reports to state leaders. It also advises the State Office on the operation of an effective child fatality prevention system. The Task Force has one staff member, an Executive Director, located in the Office of the Secretary of the NC Department of Health and Human Services. The Task Force has been in existence since 1991, however recent legislation expanded its duties and created new connections among the Task Force, the State Office, the Office of the Chief Medical Examiner, and Local Teams.

• Medical Examiner Child Fatality Staff

These staff members work in the Office of the North Carolina Chief Medical Examiner and investigate child deaths under ME jurisdiction. They coordinate with broader CFP System, contribute medical examiner reports to inform Local Team reviews, and provide training law enforcement on child death investigations.

Teams

Local Teams are multidisciplinary child death review teams operating in all 100 counties with 15+ member seats established by statute. Teams may organize as single-county teams or form multi-county teams, though all currently operate as single-county teams in each county. Each team is led by an elected chairperson and supported by a review coordinator.

Local Teams:

• Review child deaths and develop findings and recommendations
• Submit reports to local leaders and the State Office of Child Fatality Prevention
• Receive support from the State Office
• Receive administrative support from local health departments and social services agencies
• Implement prevention initiatives in their communities

The North Carolina Child Fatality Task Force studies a variety of data surrounding child deaths including information from local child death reviews and information on prevention strategies related to child deaths; it does not review individual deaths. It receives reports from the State Office of Child Fatality Prevention containing aggregate information from Local Team reviews, information on the functioning of the statewide Child Fatality Prevention System, and on other child fatality-related matters. The Task Force submits an annual report to state leaders that addresses child death data, the functioning of the child fatality prevention system, as well as policy and other recommendations to prevent child deaths and support child well-being. The Task Force also engages in collaborative work to advance prevention initiatives and broadly shares and educates about child death data and prevention information.

Reviews

Local Teams are required to review child deaths of resident children ages 0 to 17 that fall under nine categories of death:

1. Undetermined causes
2. Unintentional injury
3. Violence
4. Motor vehicle incidents
5. Sudden unexpected infant death
6. Suicide
7. Deaths not expected in the next six months
8. Deaths related to child maltreatment or child deaths involving a child or child’s family who was reported or known to child protective services*
9. A subset of additional infant deaths that fall outside of the above categories (determined by criteria set by perinatal health experts)

Local Teams have the option to review additional deaths that fall outside of the above nine categories.

*Deaths involving child maltreatment and deaths where there has been child protective services involvement with the family undergo “escalated” reviews by Local Teams with assistance & information from the State Office of Child Fatality Prevention as well as state & local social services agencies. These reviews may also be informed by information from separate internal reviews conducted by the State Division of Social Services. Information from these Local Team reviews may also be requested by Citizen Review Panels.

Purpose

The purpose of North Carolina’s Child Fatality Prevention system is to:

• Collect, analyze, and report data related to child deaths.
• Utilize multidisciplinary teams to review child deaths and better understand the factors contributing to child deaths.
• Identify system-level challenges and evidence-driven prevention strategies.
• Develop and implement recommendations to prevent child deaths, reduce child maltreatment, and promote child well-being.

Recommendations may involve state or local action including system changes, changes in law or policy, or the implementation of various types of prevention initiatives.

Data

Beginning January 1, 2026, the North Carolina Child Fatality Prevention System will begin using the NFR-CRS data system to track, analyze, and report information from Local Team. Each Local Team will be provided information from State Center for Health Statistics, Office of the Chief Medical Examiner, and State Department of Social Services to supplement their reviews and will be responsible for entering their review information into the NFR-CRS. The State Office of Child Fatality Prevention will analyze this information and provide aggregate reports to State and local agencies, including the Child Fatality Task Force, who reports data and recommendations in its annual report to state leaders.

Annual Report

Local Teams are required to submit an annual report to their board of county commissioners that includes recommendations for systemic improvements and needed resources to address identified gaps and deficiencies in the existing system. The report is also submitted to the State Office of Child Fatality Prevention. Reports on Local Team activities are also submitted to local boards of social services and local boards of health.

The Child Fatality Task Force is required to submit an annual report to the governor, the General Assembly, the Secretary of the Department of Health and Human Services, and chairs of several legislative committees. The report is also widely shared with the public. The report addresses data surrounding child deaths (including relevant aggregate data and information learned from child death reviews by Local Teams), a summary of activities and functioning of the Child Fatality Prevention System as a whole; and recommendations for changes to any law, rule, policy or for the implementation of evidence-driven prevention strategies that will promote the safety and well-being of children. [Note that requirements in state law expanding the contents of the report to include Local Team information and information on the functioning of the CFP System did not go into effect until July 1, 2025.]

Prevention Initiatives

The Child Fatality Prevention System has had a significant impact on preventing child deaths, child maltreatment, and promoting child well-being since it began in 1991.

LOCAL EFFORTS: Local Teams have led community-specific prevention efforts for many years. Recent examples reflecting the efforts of Local Teams include:

• Safe Sleep Education & Promotion
  • Billboards, flyers, door hangers, social media campaigns
  • Training for EMS, DSS, foster parents, first responders
  • Distribution of Pack ‘n Plays by DSS, health departments, Safe Kids, CMARC, CMHRP
• Car Seat Safety & Distribution
  • Car seat checks and education (Safe Kids, diversion programs)
  • Technician certifications
  • Distribution through CMARC, CMHRP, senior centers, retail partners
• Gun Safety & Lock Distribution
  • Free gun locks at health departments and community events
  • Flyers and education on firearm safety
  • Integrated into child safety kits
  • Public service announcement (PSA) development
• Water Safety Initiatives
  • Life jacket loaner stations
  • Promotion of swimming lessons
  • Pool and water safety social media outreach
• Community Events & Fairs
  • Participation in festivals and family events with safety resources
  • Child Abuse Prevention Month activities (e.g., pinwheel planting)
• Mental Health & Suicide Prevention
  • Partnerships for youth suicide prevention
  • Social media awareness campaigns
  • Support for youth mental health organizations
• Substance Use & Opioid Initiatives
  • Naloxone distribution (via opioid settlement funds)
  • Fentanyl education in schools
  • Creation of substance use task forces
• Train Safety & Hot Car Awareness
  • Train safety education campaigns
  • Hot car displays with sheriff/fire department partners
• Injury Prevention
  • Distribution of medication lock bags, cabinet locks, outlet covers
  • Safe storage campaigns (guns, medications)
  • “Period of Purple Crying” education for new parents
• Early Intervention & Parenting Support
  • Truancy-focused early intervention teams
  • Parenting class referrals tied to safe sleep kit distribution
  • Strengthened prenatal care referrals

STATE EFFORTS: At the state level, many laws and initiatives reflecting recommendations from the Child Fatality Task Force (some of which have been informed by Local Team recommendations) have advanced since creation of the Task Force in 1991, and a summary of accomplishments can be found here on the Task Force website. A few of many examples include the following:

• Second in nation to pass laws for a graduated driver license
• Strengthened child passenger safety laws
• Poison prevention funding, and packaging requirements for liquid nicotine
• Firearm safe storage education and awareness
• Improvements to child welfare laws & court process
• Improving birth outcomes through increased Medicaid funding to incentivize group prenatal care and increase maternity care reimbursement rates to attract and retain maternity providers
• Improved birth defects screening and prevention
• Funding programs to prevent sleep-related infant deaths
• Youth suicide prevention through requiring suicide prevention training for school personnel and funding for programs to address access to lethal means
• Strengthening the child fatality prevention system
• Improved recognition & reporting of child maltreatment
• Support for diagnosis and treatment for abused or neglected children
• Infant safe surrender laws
• Funding for tobacco and nicotine use prevention
• Requirements related to smoke and carbon monoxide detectors

Protocols

The State Office provides guidance and protocols for Local Teams. State statutes address confidentiality and access to information used for system purposes. The Child Fatality Task Force also has policies and procedures to guide its operations.

Training

The State Office offers training for Local Teams on a rolling basis. In addition to a procedural manual to guide the Local Team process, State Office staff provide rolling orientations to new Local Team chairs and review coordinators. Recent Trainings have been focused on the new 2023 legislation transition and preparation for use of the NFR-CRS.

Statewide Child Fatality Prevention Summits have been held in the past, bringing together professionals across the system to share knowledge, learn from one another, and learn from experts. In recent years, these summits have been made possible through external funding and partners, and future summits will depend on the availability of resources.

The Child Fatality Task Force distributes a member orientation guide to all new members, and its Executive Director hosts a yearly informational webinar for new members.

Tools

The State Office provides tools and resources to support the work of Local Teams and system partners. For additional information, please reference our website.