CDR Map - The National Center for Fatality Review and Prevention

Map of CDR Programs

Click on each state or territory to learn more about their Child Death Review program, state leadership, process and prevention work. To view a summary of CDR programs in the US, see our Profile Dashboard at https://fatalityreviewdata.org/

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Map of US State/Territories with a Child Death Review Program

Alabama

Program Description

Administration

The Alabama Child Death Review System (ACDRS) was established by statute (Section 26-16-90 et seq.) in 1997. ACDRS has an annual budget of approximately $300,000 that is funded by Children’s First legislation. This legislation receives its financial support from the National Tobacco Settlement. These settlement monies are appropriated year to year. Those funds are supplemented by a Medicaid reimbursement agreement which provides additional funding exclusively for outreach and education efforts.

The program is administratively located within the Alabama Department of Public Health, Bureau of Health Promotion and Chronic Disease. Three full-time employees staff the program at the state level. These positions are a Director, a Public Health Educator, and an Administrative Assistant.

Teams

Alabama has both state and local CDR teams which are mandated. The Alabama Child Death Review System is a member of the Southeast Coalition of Child Death Review.

State Team: The team consists of 28 members and meets quarterly. The team is responsible for identifying trends that place children at risk and identifying interventions that will prevent further deaths. This team makes recommendations for changes in state statute, regulation or policy. They also support local teams training and service needs.

Local Teams: For most local teams, the District Attorney serves as the chair. Each team has a Coordinator who is responsible for receiving death certificates, collecting review information and convening the meetings. The Coordinator is also responsible for completing the data collection tool and sending the information to the State Office. There is at least one local team in each of Alabama’s 41 judicial circuits that meet at least once per year, and more as needed based upon caseload. These teams are responsible for making recommendations that are communicated to the State CDR Team. Local team reviews are retrospective and in-depth. Local team members serve as volunteers.
Reviews

Local Alabama CDR teams review unexpected and unexplained deaths to children less than 18 years old. The State Alabama CDR Office is responsible for sending child death certificates to local teams to assist in their review process.

Purpose

ACDRS’s mission is to understand how and why children die in Alabama, in order to prevent future child deaths.

Data

Standardized data are collected for all review cases. The local Coordinator submits information to the State Office electronically via the National MCH Center’s online system. The CDR program utilizes department staff to analyze the data for the Annual Reports. The Alabama CDR program has access to all state vital statistics data for child death cases.

Annual Report

Alabama produces an Annual Report that is distributed to the Governor, Legislators, various State Agencies, and elsewhere throughout the state.

Prevention Initiatives

ACDRS findings have influenced policy changes in Alabama. Some statewide examples include Safe Infant Sleep initiatives, the Alabama SUIDI Law, the Secret Safe Place for Newborns, Statewide Abusive Head Trauma (formerly Shaken Baby Syndrome) awareness and prevention campaigns, changes in policies and regulations of licensed child day care centers, primary seatbelt legislation, and a recently enhanced Graduated Driver’s License law.

Protocols

Alabama has a variety of protocols, including those for CDR meetings, child death investigations and confidentiality requirements.

Training

ACDRS routinely offers both live and online training for all state- and local-level participants. ACDRS is also involved prominently in developing and offering SUIDI training in Alabama.

Last Updated: March 2023

Program Contact

Spencer Avant, MSW LBSW
Child Death Review Coordinator
Alabama Department of Public Health
Bureau of Prevention, Promotion, and Support
RSA Tower, Suite 960
201 Monroe Street
Montgomery, AL 36104
Phone (334) 206-2085
Email: Spencer.Avant@adph.state.al.us

Website: Alabama Child Death Review

Tools

Arizona

Program Description

Administration

The Arizona CFR (CFR) Program was established in order to review factors in a child’s death and determine ways to reduce or eliminate any identified preventable fatalities. Legislation passed in 1993 (A.R.S. § 36-342, 36- 3501-4) authorizing the creation of the CFR Program. Data collection and case reviews began in 1994. Since 2005, the program has reviewed the death of every child in the state. The Arizona Department of Health Services’ Division of Prevention Services administers the program. The program is housed within the Bureau of Women’s and Children’s Health: Office of Injury Prevention.
The budget for the CFR program consists of both state and federal funds. The Department of Health Services assesses an additional $1 surcharge on all certified copies of death certificates to help fund the CFR program.

Teams

Arizona has both state and local CFR teams. The state and local teams are outlined according to A.R.S. § 36-3501 and 36-3502.

State Team: (Chairperson – Dr. Mary Rimsza, MD)
The team is comprised of 21 statutorily required members, meets annually and reviews the findings from the local teams in order to provide an annual report and data driven prevention recommendations each year.

Local Teams:
Arizona has 11 Local County CFR Teams who complete reviews at the county level (second level reviews of sudden unexplained infant deaths (SUID) and maltreatment deaths are done at the State level). Teams meet as needed to complete reviews of all child deaths in their jurisdiction. However, in Maricopa County, Arizona’s largest county, the local county team has several sub-committees focusing on specific types of deaths including homicide, natural, suicide, undetermined, motor vehicle crash, and other accidents.

Reviews

The Arizona CFR teams review deaths to of all children, excluding fetal (intrauterine) deaths, less than 18 years old that die in Arizona. If an Arizona resident dies outside of the state, local teams do not review the case.

Purpose

To reduce preventable child fatalities through systematic, multidisciplinary, multi-agency and multi-modality review of child fatalities in Arizona through interdisciplinary training, community-based prevention education, and data-driven recommendations for legislation and public policy.

Data

The Arizona CFR program has access to state vital statistics, and the program receives death certificates for all children who died in the state. These death certificates help trigger the review as well as provide demographic information. Arizona uses the National Database for all data reporting. Local teams enter the review data into the National Database, and the state program analyzes the data. The state program also fulfills requests for aggregate de-identified data.

Annual Report

Arizona produces a statutorily required annual report due to the governor by November 15 of each year. The CFR program provides the report to the governor, legislature, agency partners, the media, and local CFR teams.

Prevention Initiatives

CFR findings have influenced policy changes in Arizona. Statewide changes in laws have occurred because of recommendations from Arizona’s State CFR team to the legislature. Many local community policy changes have also occurred because of CFR findings. There have been ordinance changes regarding pool fencing, licensing for teen drivers, a requirement for an infant death checklist completed by law enforcement, and child safety restraints. Arizona’s CFR findings have also motivated prevention activity, most recently the launch of a statewide safe sleep prevention campaign in fall 2015.

Protocols

Arizona has a variety of protocols in place including local CFR meetings, unexplained infant death investigations, second level reviews of SUID and maltreatment cases, and strict confidentiality.

Training

Arizona CFR offers training and technical assistance for local teams and partner agencies. Quarterly meetings are held with local coordinators in which staff share information on team protocols and/or other issues related to the CFR process. Sometimes guest speakers are invited to present on a specific topic. The CFR program also provides infant death scene investigation training for local law enforcement and first responders

Last Updated: January 2019

Program Contact

Morgan Anderson, MPH
Child Fatality and Maternal Mortality Review Program Manager
Office of Assessment and Evaluation
Arizona Department of Health Services
150 North 18th Avenue, Suite 320
Phoenix, AZ 85007
Office: (602) 364-4683
Email: Morgan.Anderson@azdhs.gov

Website: http://www.azdhs.gov/phs/owch/ipcfr/cfr.htm

Tools

Arizona Child Death Review Legislation

Reports

Alaska

Program Description

Administration

Alaska has two review programs: The Maternal and Child Death Review (MCDR) and the Child Fatality Review Team (CFRT).

MCDR has been in place since 1989. Initially, the program only reviewed maternal, infant and occasionally fetal deaths. In 2005, the age criterion was expanded to include children. The age range of children has varied over time; currently MCDR reviews infants and children 0 – 17 years of age statewide. Alaska’s MCDR staff consist of a Program Manager, Epidemiologist, Health Program Associate and a consulting Senior Epidemiologist. Federal funding like the Title V MCH Block Grant and the CDC SUID grant are blended to fund these positions which are housed in Alaska’ Title V Agency, within the Section of Women’s, Children’s, and Family Health of the Alaska Division of Public Health.

CFRT was established by statute (section 12.65.120 to .140) in 1998. There is no budget for this program, and it is housed in the State Medical Examiner’s Office.

Teams

MCDR committee members are on a voluntary basis and are approved by the Commissioner of the Department of Health and Social Services and the State of Alaska Medical Board. Committee membership includes medical providers such as pediatricians, neonatologists, obstetricians, and nurses, as well as social workers, epidemiologists, tribal representatives, and children’s justice advocates.

CFRT committee members are specified in Alaska statute. This CFRT state-level team is mandatory. The chairperson of the state team is the Chief Medical Examiner. The state team conducts retrospective/periodic reviews. Local teams are permitted, although none currently exist.

Reviews

The MCDR program reviews maternal cases and infant and child deaths ages 0 – 17. All deaths occurring in the state of Alaska or among Alaskan residents that meet these criteria are reviewed. All reviews are conducted retrospectively, with the committee meeting once a month.

The CFRT program reviews all deaths ages 0-17 that are unanticipated, sudden, or violent, focusing on legal and law enforcement activities surrounding the death and only reviewing those deaths that go through the State Medical Examiner’s Office. All reviews are usually completed within one month of the time of death.

Purpose

The final products of MCDR are reports with public health recommendations.

The final product of CFRT is a decision on legal action and decision on cause and manner of death to put on the death certificate.

Data

MCDR utilizes standardized data reporting forms, which are completed for all reviews. All information is then entered and stored in the National Fatality Review Case Reporting System which is accessed for analysis.

Annual Report

Reports are published on a quarterly basis. Additionally, topic-specific Epi Bulletins, fact sheets, presentations, and other reports are developed to inform the public about specific risk and protective factors impacting infants, children, or mothers as well as to increase awareness about prevention opportunities.

No CFRT reports have been published.

Protocols

Both MCDR and CFRT have meeting and confidentiality protocols in place.

Training

MCDR holds an annual joint summit with the perinatal quality collaborative, during which speakers are selected based on MCDR data and identified need areas. Topic-specific virtual trainings are identified and shared with panelists as they become available and as needed. Occasionally, new trainings are developed when a particular need arises (e.g. a training on Hmong culture, birthing practices and historical trauma was developed to improve panelists’ understanding of this population before completing review of deaths from within this community.)
New panelists receive an orientation packet and initial training about the review process.

Last Updated: May 2021

Program Contact

Jared Parrish
MCDR Program Manager
State of Alaska, DPH, WCFH, MCH Epidemiology
3601 C Street, Ste. 358
Anchorage, AK 99503
Phone: 907-269-4907
Email: doh.mcdr.info@alaska.gov

Website: http://dhss.alaska.gov/dph/wcfh/Pages/mchepi/mcdr/default.aspx

Tools

Alaska Child Death Review Legislation

Reports

Quarterly Reports and Fact Sheets

Arkansas

Program Description

Administration

The Arkansas Child Death Review (CDR) Panel was established through passage of Arkansas Act 1818 of 2005 as a committee within the Arkansas (AR) Commission on Child Abuse, Rape and Domestic Violence. The panel is required to include members from nine specific professions and may include additional professionals as needed. The AR CDR Panel and the Injury Prevention Center (IPC) of AR Children’s Hospital provides oversight to the Arkansas Infant & Child Death Review (ICDR) Program which was started in 2011.

The director of the AR ICDR Program is Kristyn Jeffries, MD, who serves as an Associate Professor of Pediatrics in the Division of Pediatric Hospital Medicine at the University of Arkansas for Medical Sciences and Arkansas Children’s.

The coordinator of the AR ICDR Program is Ashlee Jackson. Laura Taylor, MPH, is the Director of Community Impact and oversees administrative duties and the data collection process for the project.

Teams

State Level: Arkansas Infant & Child Death Review Program
The AR ICDR Program is the intermediary between the AR CDR Panel and the local ICDR teams. The program was established in 2011 and funding is provided by the Family Health Branch of the Arkansas Department of Health (ADH).

Local Teams:
Local teams are comprised of multi-disciplinary professionals that systematically collect, analyze and discern external factors that led to the infant/child’s death within the community. Currently there are eleven teams in Arkansas covering all 75 counties. Each team of volunteers has a director and coordinator and representatives from the following agencies and disciplines: the Crimes Against Children Division of the AR State Police; the AR Department of Human Services, Division of Children and Family Services; Emergency Medical Services; Law Enforcement; Medical Examiner; County coroners; Pediatrician (or nurse with specialized training); Prosecuting Attorney’s Office; and Public Health. Each team meets quarterly.

Reviews

To ensure a coordinated response that addresses all programmatic concerns surrounding pediatric deaths in Arkansas, the AR Legislature granted the AR CDR Panel and designees the authority to gather all relevant records necessary for comprehensive reviews to be performed. All records obtained for reviews are confidential.

Exceptions to team reviews include cases that are currently under criminal investigation or prosecution. The AR ICDR Program is notified of deaths through the release of death information (and corresponding birth information) from the Arkansas Department of Health, Health Statistics Branch. The AR ICDR Program then determines which deaths are ineligible for review (based on existing legislation) and forwards the eligible cases to the appropriate local team.

Vision Statement

Eliminate all preventable infant and child deaths in Arkansas.

Mission

To review all unexpected infant and child deaths in the state of Arkansas. These reviews result in the development of interventions and recommendations through multi-disciplinary team collaboration, community education, and policy.

Data

Eleven local teams have been established and perform case reviews. AR has a data use agreement with the Michigan Public Health Institute for internet-based data reporting and retrieval.

Annual Report

The AR ICDR Program produces an annual report in December.

Prevention Initiatives

Local multi-disciplinary and multi-agency reviews of infant and child deaths assist in improving pediatric death investigations; developing a greater understanding of the incidence and causes of these deaths; identifying prevention strategies; and identifying gaps in services to children and families. The AR ICDR collaborates with the IPC on prevention initiatives based on recommendations from local ICDR teams. Since FY 17 the ICDR program has developed statewide prevention initiatives to reduce child deaths. In FY 17 the safe sleep initiative was launched followed by suicide prevention in FY 18, and motor vehicle safety in 2021. The three specific campaigns will continue, through the ICDR, for the next 3 to 5 years.

Protocols

The AR ICDR Program, with the consensus of the CDR Panel, has developed a Standard Operating Procedure Manual (SOP)based on AR law, policy and best practices.

Training
The AR ICDR Program hosts an annual one and half day training for team members. Training topics vary year to year based on the needs of the program. One-on-one topic specific training is provided to individual teams as needed.

Last Updated: March 2026

Program Contact

Andrea Weston
Community Engagement Coordinator
Injury Prevention Center
Arkansas Children’s Hospital
Center for Applied Research and Evaluation
University of Arkansas for Medical Sciences
1 Children’s Way, Slot 669
Little Rock, AR 72202-3591
Phone: 501-364-3388
Fax: 501-364-3112
Email: WestonAN@archildrens.org

Secondary contact:
Semeria Hill
Infant and Child Death Review Program Supervisor
Phone: 501-364-4013
Email: hillsa@archildrens.org

Website: https://www.archildrens.org/injury-prevention-center/infant-and-child-death-review

Tools

Reports

California

Program Description

Administration

Currently in California there is no state child death review (CDR) team. The mandate to the Attorney General’s Office for a state team is contingent upon funds being available. The State Child Death Review (CDR) Council was disbanded in 2008 when state funds were cut. Local Child Death Review Teams (CDRTs) have been functioning since the early 1980s, with Los Angeles County starting in 1978. Most California counties continue to maintain CDRTs, however they are formally authorized (not mandated) in statute (Penal Code §11174.32 Section). A loose network of regional CDRT coordinators exists to maintain communication among local CDRTs and state agencies. The California Department of Public Health (CDPH) created the Fatal Child Abuse and Neglect Surveillance (FCANS) Program in 2000 to carry out its mandate to track data on fatal child abuse and neglect (Penal Code §11174.34 Section). General funds for this program were cut in 2008. However, funding is provided for local assistance under the federal Maternal Child Adolescent Health Title V Block Grant. Approximately $150,000 local assistance money is used to provide support for local teams.

Teams

Currently, California only has local county teams. The State CDR Council was disbanded in 2008 when state funds were cut. The mandate for a state team is contingent upon funds being available.

State Team Chairperson: N/A

A loose network of regional coordinators continues to exist to maintain communication among local CDRTs and state agencies.

Local Teams:

Based on the limited information available to us, there could be up to 37 active local CDR teams. Meeting schedules vary by team.

Reviews

Most California CDRTs review all sudden, traumatic and/or unexpected child deaths (i.e., Coroner cases), including injury, natural and undetermined deaths. Review selection criteria vary by team. Generally, teams review cases of children that are less than 18 years old.

Purpose

Prevention is the overriding priority, but California’s CDRTs have several objectives: 1) to assist in identifying and investigating potential child maltreatment cases; 2) to assist in protecting siblings and other children; 3) to identify and assist in improving agency and systems problems; and 4) to prevent future child deaths from all causes through identifying the circumstances surrounding child deaths and developing recommendations and effective action.

Data

The FCANS Program adopted the National Center for Child Death Review Case Reporting System for local teams to report to the state. Standardized data reporting forms are completed by local CDRTs for mandated cases and for many other reviewed cases as well. In addition to the local teams using their own data, the state FCANS Program aggregates and manages the statewide data.

Annual Report

California has not produced an annual state report for several years due to budget cuts and a lack of a State Council. Under a new state statute, county teams (if they exist) are required to make available their findings and aggregate data annually. Many county CDRTs now have annual reports that are made available to the general public.

Prevention Initiatives

CDR findings have influenced both state and local policy and program changes in California. Statewide laws on child homicide sentencing, safely surrendered babies, children left alone in cars (Kaitlyn’s Law), and child maltreatment reporting and data collection have been enacted. Local and state policy changes have resulted in residential pool safety barrier laws and zero tolerance for carrying guns on school property. California’s CDR findings have motivated prevention activities including public education on child maltreatment prevention in general, and Shaken Baby prevention specifically, Sudden Unexplained Infant Deaths and promotion of safe sleep environments and practices, teen suicide and motor vehicle crash prevention, perinatal substance exposure and parental substance abuse. Reports to the Consumer Product Safety Commission have led to national actions (e.g., 5 gallon buckets, baby bath seats, & unsafe cribs and beds). Although attribution of impact is difficult, CDRTs have been directly responsible for many of these successful activities.

Protocols

California has a variety of protocols in place addressing death investigations conducted by Coroners/Medical Examiners, Law enforcement and child welfare professionals. California relies on the National CDR Center Program Manual, which it helped to develop, for protocols on CDRT functioning and confidentiality requirements.

Training

The CDPH FCANS Program is working with partners to identify ways to provide support on CDRT functioning, data collection, writing effective recommendations and taking findings to action. Various state departments have funded team training in the past.

Last Updated: May 2021

Program Contact

Celeste Doerr, PhD
Manager, Epidemiology, Surveillance, and Evaluation Section
Injury and Violence Prevention Branch
Center for Healthy Communities
California Department of Public Health
P.O. Box 997377, MS 7214
Sacramento, CA 95899-7377
Email: Celeste.Doerr@cdph.ca.gov

Website:http://www.cdph.ca.gov/programs/Pages/ChildMaltreatmentPrevention.aspx

Tools

California Child Death Review Legislation

Reports
Mortality Statistics can be found at:

California Department of Health Center for Health Statistics: Vital Data Query Tool

Colorado

Program Description

Administration:
Child deaths have been reviewed in Colorado since 1989. However, the Child Fatality Prevention System (CFPS), as it exists today, was established in 2005 and codified in 2013 under Section 25-20.5-401, C.R.S. Operated within the Colorado Department of Public Health and Environment (CDPHE), CFPS is a statewide, legislatively mandated, multidisciplinary, and multi-agency network dedicated to preventing child deaths. It reviews fatalities of children aged 0-17 across Colorado to identify trends, develop prevention strategies, and reduce child deaths statewide. CDPHE provides core oversight, funding, and technical support to local review teams across Colorado. Through ongoing interagency partnerships, CDPHE ensures that review processes align with public health best practices and statutory requirements.

Teams:
CFPS is composed of three tiers:

Local Review Teams. Each county or regional team in Colorado is served by a multidisciplinary local child death review team. These teams include representatives from public health, medical examiners or coroners, behavioral & mental health, law enforcement, child welfare, education, medical care, and community stakeholders. Their role is to review child deaths within their jurisdiction and to develop locally relevant prevention recommendations.

State Review Team. The State Review Team is a volunteer, multidisciplinary body whose expertise spans child injury prevention, pediatrics, forensic investigation, public health, and related fields. It examines aggregated findings submitted by the local teams, formulates systemwide recommendations, and reports to the legislature annually.

State Support Team (CDPHE). CDPHE staff form a State Support Team that provides funding oversight, technical assistance, training, data analytics, and facilities coordination across local teams and other state systems. CDPHE provides ongoing training, technical assistance, and capacity building to support robust and actionable reviews. Activities include:

In-person or virtual training sessions on review methods, root cause analysis, systems thinking, and prevention strategy development.
Continuous support via consultation, peer sharing, and resource dissemination.

Teams are encouraged to participate in professional development and learning exchanges to stay current with advances in child death review and prevention science.

Reviews:
Local review teams perform in-depth reviews of deaths of children and young people aged 0-17 years old that occurred within their jurisdictions. These reviews include:

Identification of potential contributing factors and system gaps.
Development of prevention recommendations tailored to their community.

The scope of review covers a broad array of death types, including but not limited to

Child maltreatment (abuse and neglect)
Homicide
Motor vehicle crashes
Sudden Unexpected Infant Deaths (SUIDs)/sleep-related infant deaths
Suicide
Undetermined causes
Unintentional injuries (e.g., poisoning, drowning, fires, falls)
Water-related

CFPS applies a public health framework to understand and prevent child deaths. The purpose is to:

Identify trends, contributing factors, and systemic gaps.
Generate actionable prevention recommendations.
Inform policy, programs, and community interventions.
Strengthen Colorado’s capacity to keep children safe and healthy.

The review process is not intended to assign civil or criminal liability, but rather to learn from past events and drive forward prevention strategies and systems improvement.

Data:
CFPS local teams use the National Center for Fatality Review & Prevention’s (CFRP) Case Reporting System (CRS) as the repository for death review data, enabling standardized collection across jurisdictions. Additionally:

State vital records are use for identification, demographic context, and trend analysis.
Aggregate analyses are performed annually to identify patterns, rates, and circumstances associated with child fatalities across Colorado )by cause, county, demographics).
Selected data (e.g. leading causes, circumstances of death) are made public via the CFPS Data Dashboard, along with any data briefs, local team reports, and legislative summaries.

Prevention Initiatives:
CFPS review findings have led to statewide and local prevention actions in Colorado. Examples include:

Development of child passenger safety and car seat promotion programs.
Changes to the built environment to reduce motor vehicle incidents and deaths.
Increased public awareness campaigns around safe sleep and seat belt use.
Policy enhancements such as graduated driver licensing laws.
Distribution of gun locks, helmets, and child safety equipment.
Collaboration with partners to support youth development, mental health screening, and community safety strategies.
Development of a water safety campaign.
Leveraging review findings to create prosocial events and mentorship programming.

Annual Report:
In accordance with statutes, CFPS produces an annual legislative report that is submitted to the Governor and the Colorado General Assembly by July 1st each year. The report includes:

Aggregate findings from local and state child death reviews.
Prevention recommendations spanning law, policy, systems, and practice.
Data summaries or trends of concern.
Highlights of priority areas and suggested next steps.

Last Updated: October 2025

Program Contact

Shiv Sunger
Child Fatality Prevention System Manager
Colorado Department of Public Health & Environment Prevention Services Division
4300 Cherry Creek Drive South
Denver, CO 80264-1530
Phone: 303-692-2947
Fax: 303-691-7901
Email: cdphe_prevent_childfatality@state.co.us

Website: https://cdphe.colorado.gov/prevention-and-wellness/maternal-and-child-health/child-fatality-prevention-system

Tools

Colorado Legislation

Reports

2025 CFPS Annual Legislative Report

Connecticut

Program Description

Administration
The Connecticut Child Fatality Review Panel (CFRP) was established in 1995 by statute (§§ 46a-13l(b) and (c ), The impetus for the creation of a child fatality review process came about as a result of a high profile infant death (Baby Emily). The Governor convened two multi-disciplinary panels to provide a series of recommendations related to the tragic death of Emily; one such recommendation was the creation of the Child Advocate Office and within the OCA statue is the mandate for a child fatality review process.

Child fatality reviews began shortly after the enabling legislation was passed. Currently, the program is housed out of the Office of the Child Advocate. The program’s annual budget is $150,000 which comes from the State of Connecticut. There is one full-time and one part-time staff person that devotes primary attention to child fatality review and related issues.

Teams
Connecticut, like most of New England, has a State Child Fatality Review Panel (CFRP) and no local teams. Initially, the CFRP was given the mandate of reviewing the circumstances involved in the death of a child who received service from a state department or agency addressing child welfare, social or human services or juvenile justice. In October 1999, the Governor and Legislature authorized the panel to review all unexpected or unexplained deaths.

There is established a child fatality review panel composed of thirteen permanent members as follows: The Child Advocate, or a designee; the Commissioners of Children and Families, Public Health and Public Safety, or their designees; the Chief Medical Examiner, or a designee; the Chief State’s Attorney, or a designee; a pediatrician, appointed by the Governor; a representative of law enforcement, appointed by the president pro tempore of the Senate; an attorney, appointed by the majority leader of the Senate; a social work professional, appointed by the minority leader of the Senate; a representative of a community service group appointed by the speaker of the House of Representatives; a psychologist, appointed by the majority leader of the House of Representatives; and an injury prevention representative, appointed by the minority leader of the House of Representatives. A majority of the panel may select not more than three additional temporary members with particular expertise or interest to serve on the panel. Such temporary members shall have the same duties and powers as the permanent members of the panel. The chairperson shall be elected from among the panel’s permanent members. The panel shall, to the greatest extent possible, reflect the ethnic, cultural and geographic diversity of the state.

The panel shall review the circumstances of the death of a child placed in out- of-home care or whose death was due to unexpected or unexplained causes to facilitate development of prevention strategies to address identified trends and patterns of risk and to improve coordination of services for children and families in the state. Members of the panel shall not be compensated for their services, but may be reimbursed for necessary expenses incurred in the performance of their duties.

On or before January 1, 2000, and annually thereafter, the panel shall issue an annual report which shall include its findings and recommendations to the Governor and the General Assembly on its review of child fatalities for the preceding year.

Upon request of two-thirds of the members of the panel and within available appropriations, the Governor, the General Assembly or at the Child Advocate’s discretion, the Child Advocate shall conduct an in-depth investigation and review and issue a report with recommendations on the death or critical incident of a child. The report shall be submitted to the Governor, the General Assembly and the commissioner of any state agency cited in the report and shall be made available to the general public.

The Office of the Chief Medical Examiner shall provide timely notice to the Child Advocate and to the chairperson of the child fatality review panel of the death of any child that is to be investigated pursuant to section 19a-406.

Any agency having responsibility for the custody or care of children shall provide timely notice to the Child Advocate and the chairperson of the child fatality review panel of the death of a child or a critical incident involving a child in its custody or care.

Reviews
The Office of the Chief Medical Examiner primarily identifies the deaths for the Panel to review. However, statute allows the Panel to review any death that occurs in the state. There is a particular emphasis on children placed in out-of-home care or known to state systems. Cases are reviewed regarding children that are less than 18 years old. The Panel reviews about 120+ deaths per year, about half (60) are child deaths from unintentional and intentional injuries. The Child Advocate can subpoena records and witnesses for the review process if they choose. Some child death reviews will become full fatality investigations that result in a public report.

Purpose
The main purpose of the Connecticut CFRP process is to facilitate the development of prevention strategies to address identified trends and patterns of risk and to improve coordination of services to prevent child deaths. The panel’s purpose is to save lives by learning from lives lost.

Data
Standardized data forms are completed for all cases reviewed. Connecticut is also part of the National Child Fatality Data System.

Annual Report
Connecticut produces an annual report on trends and patterns of child fatalities. The annual report is a section in the Child Advocate annual report. Connecticut also produces trend reports in child death; both a 10 year review and a 5 year review, combining 15 years of trend data. Connecticut produces many major investigative reports and public health alerts related to child fatalities, all of which are made available to the public.

Prevention Initiatives
The Panel will focus on policy and systemic issues related to children’s deaths. Examples include tightening up the graduated drivers licensing law, suicide prevention initiatives and partnering with other prevention entities to support systemic change related to child safety and well-being. Other examples of outreach include training on how children die, utilizing the panel’s data to support and inform various community initiatives including shaken baby/abusive head trauma and infant safe sleep. The Panel also publishes public health alerts related to child fatalities.

Training
The child fatality coordinator provides training to community and other stakeholders on the child death review process and critical issues confronting children in the State of Connecticut.

Last Updated: March 2022

Program Contact

Brendan Burke, MSW
Assistant Child Advocate
Office of the Child Advocate
165 Capitol Avenue
Hartford CT 06106
Phone Number: 860-566-2106
Toll-Free: 800-994-0939
Fax: 860-326-0569

Email: Brendan.Burke@ct.gov

Website: http://www.ct.gov/oca

Tools

Connecticut Child Death Review Legislation

Reports

District of Columbia

Program Description

Administration
The District of Columbia Child Fatality Review (CFR) Committee was established in 1992 by a Mayor Executive Order (D.C. Act 14-40). The team began reviewing cases in 1993. The program is housed out of the Office of the Chief Medical Examiner. Funding for the program comes from District of Columbia appropriations. There are three full time employees that staff the program.

Teams
The District has two teams (Co-Chairs Dr. Roger A. Mitchell, Jr. and Cynthia Wright, Esq.) with approximately 35 members. The committee is required to have two chairs. The Mayor appoints members to the committee. Eight public members from the community are members who are recommended from each ward council. Other members include two schools of social work from colleges/universities in DC, one physician from each DC hospital, either from Child Protective Services or Pediatric Services Department, and the Consortium of Child Welfare or a private child welfare program. Ex-officio members include the head of designee from 16 agencies/ institution /committees. The committee has two case review teams that meet twice a month; Child Fatality Review and the Infant Mortality Review Teams.

Reviews
The DC CFR Committee reviews deaths to all causes to children from birth through 18 years. The Committee can choose to review cases beyond this range (through age 25 years) if the child was known to Juvenile Justice, Child Welfare or the Mental Retardation and Developmental Disabilities Systems.

Purpose
The purpose of the DC CFR Committee is to prevent child deaths and improve child, youth and family service delivery systems.

Data
Standardized data reporting forms are completed for all reviews. This is required by policy. Data is stored and analyzed using Microsoft Access. Excel is used to create spreadsheets on CFR findings.

Annual Report
The DC CFR Committee is required to produce an annual report. The report is compiled one year after the end of the calendar year. The report is available to the public and is distributed to the Mayor and committee members.

Prevention Initiatives
Findings from the CFR Committee have influenced policy and practice changes. (Example: the Committee worked with the police department in establishing a child death investigation unit. The detectives in this unit receive specialized training.)

Protocols
The DC CFR has meeting and confidentiality protocols in place.

Training
Training is offered to new members on the review process. The staff of the CFR program provides this training.

Last Updated: March 2018

Program Contact

Jenna Beebe-Aryee
Supervisory Fatality Review Program Manager
D.C Office of the Chief Medical Examiner
401 E. Street SW, 6th Floor
Washington, DC 20024
Phone: 202-465-6989
Fax: 202-698-9102
Email: jenna.beebe-aryee@dc.gov

Website:http://obc.dc.gov/obc/cwp/view,a,3,q,521195.asp#childfatality

Delaware

Program Description

Administration

Delaware’s child death review process was statutorily established on July 19, 1995, after a pilot project showed the effectiveness of such a review process for preventing future child deaths. The legislation established the Child Death Review Commission, which has been charged to create up to three regional Review Panels, establish confidentiality for the reviews, and provide the Commission with the ability to secure pertinent records. In addition, legislation provides protection to members of the Commission and regional Review Panels from civil or criminal liability.

The Commission has established three child death review panels. The Sudden Death in the Young (SDY) Panel, the secondary medical SDY panel, and the child death review (CDR) panel (state-wide review of all deaths not reviewed at SDY panel). The panels meet bi-monthly or quarterly as caseload dictates. The goal is that all cases are reviewed within six months of the death, unless there is pending prosecution. The Commission meets quarterly to review and approve the work of the Panels.

The Commission’s statute was amended in 2002, changing the name from the Delaware Child Death Review Commission to the Child Death and Stillbirth Commission. Another significant legislative change in 2002 added the expedited review process for child death due to abuse and neglect.

In 2004, the statute was amended a second time to change the Commission’s name to the Child Death, Near Death and Stillbirth Commission. Among other updates, the scope of infant review was broadened to include fetal and infant deaths from 27 weeks gestation to 20 weeks gestation. Also, the statutory change required the Commission to investigate and review all the facts and circumstances of the death or near death of an abused and/or neglected child expeditiously. The amended statute also required that system-wide recommendations arising from an expedited review of a death or near death due to child abuse or neglect be made to the Governor and General Assembly, as well as any members of the public requesting the recommendations, within 20 days following the expedited review.

In FY05, the Commission worked in collaboration with the Division of Public Health (DPH) to implement a Fetal Infant Mortality Review (FIMR) pilot project under the leadership of the Governor’s Infant Mortality Task Force. In FY06, FIMR’s budgetary positions were placed with the Commission. These three positions include a registered nurse III (FIMR Program coordinator), senior medical social worker, and an administrative specialist.

The most significant accomplishment for FY07 was the full implementation of the Fetal Infant Mortality Review Process. The bi-annual joint reviews with the Domestic Violence Coordinating Council’s Fatal Incident Review Team began in April 2007. The cases reviewed involved child deaths and near deaths with domestic violence as a significant risk factor in the death or near death. In an effort to streamline these types of reviews, a member of the Domestic Violence Coordinating Council is now a participant at every child death panel.

During FY08, the Commission’s statute was amended to include Maternal Death Review and allow for public disclosure of deaths and near deaths due to abuse and neglect, after prosecution, to fulfill the federal CAPTA (Federal Child Abuse Prevention and Treatment Act) statute mandate.

On September 20, 2015, the Governor signed legislation transferring the Child Abuse/Neglect Panel (which reviews all deaths/near deaths due to abuse/neglect) to the Child Protection Accountability Commission. CDRC will attend these meetings and will be responsible for entering these deaths into the national data tool. In addition, cases for the SDY panel or CDR panel will be jointly reviewed with the CAN panel if there are significant child welfare issues noted. As a part of this legislation, the name of the Commission was reverted to the Child Death Review Commission.

Teams

State Team(s):
The state team would be considered the Commission as outlined in state statute.

Reviews

The Commission reviews the work of three child death panels, two FIMR case review teams and one Maternal Death review team. Delaware reviews the deaths of mothers within 364 days of giving birth, children under the age of 18, and stillbirths occurring after at least 20 weeks of gestation.

Purpose

The Commission’s mission is to safeguard the children of Delaware by examining the deaths of children under the age of 18.

Data

Standardized data reporting forms are completed for all reviews. This is required by state policy. CDRC utilizes the national child death data tool for data entry. Our Fetal Infant Mortality Review program has also started to utilize the NFIMR database which is housed under the Michigan Public Health Institute. This change occurred on 1/1/2016. The program utilized the database, Baby Abstracting System and Information NETwork (BASINET), supported by Go Beyond, L.L.C. until 12/31/2015. Data is used from both databases to complete the annual report, which includes trends and recommendations. The Delaware CDRC program has access to state vital statistics. Delaware CDRC receives death certificates, fetal death certificates and birth information on all children from Delaware’s Vital Statistics.

Annual Report

CDRC statute requires that an annual report be produced by the Commission. However, due to staffing resources this has not been produced yearly. The report is distributed to public officials and interested citizens.

Prevention Initiatives
Abusive Head Trauma Program

In 2009, CDRC in collaboration with PCAD developed and implemented a statewide hospital based educational program on AHT. The program was based on the Mark Diaz Model¹, which like the Period of PURPLE Crying®² is considered the first generation of evidence-based educational media addressing AHT.

The “All Babies Cry”® abusive head trauma program is based on the Strengthening Families and Model and the Theory of Planned Behavior. The ABC program has been assessed for efficacy, using a mixed-method, quasi-experimental staged evaluation design. The results of the study showed that the program is well received, appears effective in improving mediators of behavior, and may change parental behavior. Parents are the most common perpetrators of abusive head injuries. The period of greatest risk for shaking coincides with the newborn period, particularly at eight weeks of age, when crying peaks. Childbirth is usually a time of almost universal contact between parents and the health care community. In addition, adult learning theories suggest that adults are more willing to engage in learning before, after, or during a life-changing event.
The components of the program are as follows:

All parents at all birthing hospitals and parents that have had their infants transferred to the NICU at the states only children’s hospital will receive this education prior to discharge.
All parents will be given the opportunity to view an 11-minute video at the hospital, as well as the website where the video can be viewed at home following discharge. The goal is that 75% of all birthing parents will view the 11-minute DVD.
All parents will receive a modified ABC booklet. The booklet will continue to provide information on how to access the website and the new phone “APP”. The website will provide the full 28-page, 4 color booklet with checklists, activities, hotline numbers and other resources. This booklet will also be available to download via pdf from the website.
Parents will be asked to voluntarily sign the commitment statements (CS) which state that they have received the CS and understood the information presented. The CS is produced in triplicate format. The first copy remains with the mother’s medical record. The second copy goes home with the parents/caregivers. The third copy goes to the CDRC. A statement on the CS asks the caregiver if a representative from the program may call then in six – eight weeks, to participate in a brief survey. All identifying information is blocked on the third copy to follow HIPPA regulations.
One-on-one discussion with a nurse is vital to the success of this program. A sample script was provided for nurses and requires no more than 5 minutes of their time. Nurses are also asked to document that education was offered.
Addressed stamped envelopes are provided to each hospital for each month of the year. At the end of the month, hospitals send the accumulated CS to CDRC.
A CDRC social worker continues to place follow up telephone calls and ask parents/caregivers to complete a brief survey.
The AHT Coordinator continues to remain in close contact with all hospitals to discuss their needs and how the program is going.

DELAWARE CRIBS FOR KIDS

Since 1998, through the donation of thousands of cribs, National Cribs for Kids® has been making an impact on the rate of babies dying of SIDS and from accidental suffocation. Cribs for Kids® is a safe-sleep education program to help reduce the risk of injury and death of infants due to unsafe sleep environments. Currently, Cribs for Kids® has 310 partner programs in 43 states throughout the country that provide a Graco Pack ‘n Play® crib and educational materials regarding safe sleeping and other important safety tips.³

In June 2009, a partnership was developed between the Delaware Division of Public Health, Nemours Health and Prevention Services of the Nemours Foundation (Nemours), Christiana Care and CDRC to implement the first Cribs for Kids® program in Delaware. As a result of this program, a crib is provided to any Delaware mother if she is unable to purchase a crib on her own and meets the following criteria: is due to deliver the baby within six weeks or the infant is younger than six months of age; and the family has not previously received a crib from the program. The first crib was distributed in November 2009. This program is one of the biggest accomplishments from the Joint Commission infant safe sleeping community action team.

On December 23, 2011, CDRC assumed more responsibility for this program and became the gatekeeper for all crib distribution. The designated new telephone number is 302-255-1743. The education will be provided to the family by a Division of Public Health nurse or other trained staff within the community. The preventive part of the program is the education that must be given by the nurse on unsafe sleeping practices for infants. Delaware is the only state that offers this education in the home, and has been recognized by national leaders as the gold standard versus the client picking up the crib at an office or facility. Cribs for Kids® is an evidence-based program that has had successful outcomes in other states in reducing infant unsafe sleeping deaths and is an excellent example of collaborative partnerships in Delaware on behalf of children. This program is completely funded through grants, monetary donations, and fundraising efforts.

Protocols

Delaware has a variety of protocols in place including a procedure manual and policies. All procedure and protocols must be voted upon by the Commission prior to implementation.

Policies and Procedures:

Child Death Review Commission By Laws (September 8, 2017)
Child Death Review Commission (CDRC) Policy and Procedure: Child Death Review (CDR) Panel Policy
Child Death Review Commission (CDRC) Policy and Procedure: Fetal and Infant Mortality Review (FIMR)
Child Death Review Commission (CDRC) Policy and Procedure: Maternal Mortality Review (MMR)
Child Death Review Commission (CDRC) Policy and Procedure: Statutory Duties to Report
Child Death Review Commission (CDRC) Policy and Procedure: Sudden Death in the Young Case Registry
Informed Consent—The Sudden Death in the Young Case Registry: Research, Diagnostic Testing and DNA Banking
SDY Case Registry Algorithm
Guidebook for Commissioners and Review Team Members (April 7, 2017)

Training

A one-day Advanced Training Course was offered to MDT members in partnership with the Child Protection Accountability Commission and the Centers for Disease Control and Prevention (CDC) Sudden Death in the Young Grant. It was attended by 112 professionals with direct responsibility for the investigation and prosecution of child abuse cases. Participants were given a brief introduction to the MOU for the Multidisciplinary Response to Child Abuse and Neglect. In addition, national experts taught participants how to conduct sudden unexpected infant death investigations, which included visually recreating an infant death scene using a doll; explaining the reenactment to the caregiver; demonstrating the infant’s positions; photographing the reenactment; and debriefing the family. Several doll re-enactment kits were distributed to law enforcement agencies and the Division of Forensic Science¹.

¹Diaz, M., Smith, K., deGuehery, K., Mazur, P., Li, V., & Shaffer, M. (2005). Preventing abusive head trauma among infants and young children: A hospital based parent education program. Pediatrics Vol. 115 No.4 470-477.
²Barr, r., Rivara, F., Barr, M., Cummings, P., Taylor, J., Lengua, L., & Meredith-Benitz, E. (2009). Effectiveness of Educational Material Designed to Change Knowledge and Behaviors Regarding Crying and Shaken-Baby-Syndrome in Mothers of Newborns: A Randomized, Controlled Trial. Pediatrics Vol 123 No.3 972-980.
³Through compelling research by SIDS of Pennsylvania’s Cribs for Kids® Program, a safe-sleep environment has been identified as a key factor in reducing the rates of infant death. Babies, who sleep in unsafe sleep environments, including adult beds, are at a 40 times greater risk of dying. (www.CribsforKids.org)

Last Updated: January 2019

Program Contact

Kimberly Liprie
Executive Director
Child Death Review Commission
900 King Street, Suite 220
Wilmington, Delaware 19801-3341
Phone: (302) 255-1761
Fax: (302) 577-1129
Email: Kimberly.Liprie@delaware.gov
Website:http://courts.delaware.gov/childdeath/

Reports
Annual Reports

General Reports

Delaware Commission Reports website

Collaboration with other Commissions

Florida

Program Description

Administration
The State Child Abuse Death Review Committee was established in Florida in 1999 by statute (Chapter 383.402 F.S.). Case reviews began in 2000 and were expanded in 2004 to include all verified child abuse deaths. The State Committee is a statutorily independent group supported administratively by the Florida Department of Health. The program has an estimated annual budget of $90,000, which is funded by the Florida Legislature through the Department of Health. There is one full time Quality Improvement Coordinator for the State and Local Committees, along with support by the Florida Department of Health Child Abuse Death Review Coordinator.

Teams
Florida has both a state and local review committees.

State Committee Chairperson: Connie Shingledecker
The State Child Abuse Death Review Committee has 19 members defined in Florida Statute. The Committee meets quarterly or more often as needed.

Local Teams:
As of 2011, there are 20 local committees, plus the State Committee that provides coverage for Florida’s 67 counties. The duties of the local child abuse death review committees are to:

Review all deaths reported to the Central Abuse Hotline as suspected from child abuse and neglect.
Collect data on applicable child abuse deaths for The State Child Abuse Death Review Committee.
Submit written reports to the state committee as directed. The reports are to include information on individual cases, and steps taken by the local committee to implement necessary changes and improve the coordination of services and investigations.
Submit all records requested by The State Child Abuse Death Review Committee at the conclusion of its review of a death resulting from child abuse or neglect.
Abide by standards and protocols established by The State Child Abuse Death Review Committee in the conduct of child abuse death reviews.
Designate a committee chairperson who oversees activities and calls meetings of the committee when necessary.
Designate a member of the local committee, if there is not a state committee member on the local committee, to liaison to the state committee for the purpose of ensuring consistency in review protocols, to present case information when requested, and to request as needed on a case-by-case basis, that the state committee reviews the data of a particular case.

Reviews
Committees are restricted to reviewing CAN deaths that are reported to the Department of Children and Families child abuse hotline. The local committees conduct reviews. The state committee analyze the data and prepares the annual report.

Purpose
The purpose of the Florida Child Abuse Death Review is prevention.

Data
Standardized data reporting forms are completed for all reviews. Florida utilizes the National CDR Case Reporting System database.

Annual Report
The State Child Abuse Death Review Committee does produce an annual report. This report is submitted to the Governor, the President of the Senate and the Speaker of the House. It is also available upon request and is posted on the committee’s website.

Prevention Initiatives
Findings from the reviews have led to prevention initiatives including safe sleep, risk assessments of who is watching your child and drowning prevention campaigns.

Protocols
Florida has a number of protocols in place including review meeting and confidentiality.

Training
Training is offered to local teams and state agencies on the review process. Training is also offered for child death investigations, mandatory reporting of child abuse and neglect, SUID training, and assessing risk to children by many of the State Members.

Last Updated: January 2020

Program Contact

Symone Ferguson
Director, Child Abuse Death Review Unit
Bureau of Child Protection & Special Technologies
Division of Children’s Medical Services
Florida Department of Health
4052 Bald Cypress Way, Bin A06
Tallahassee, Florida 32399
Office: (727) 453-5657
Cell: (850) 694-4862

Email: Symone.Ferguson@flhealth.gov

Chairperson
Connie Shingledecker
Ret. Major
Manatee County Sheriff’s Office
Email: Connie.Shingledecker@outlook.com

Website: http://www.flcadr.org/

Tools

Florida Child Abuse Death Review Program: Guidelines for State and Local Teams

Georgia

Program Description

Administration
Georgia’s Child Fatality Review Program (GCFR) was established in 1990 by statute (Section 19-15-1 et seq.). CFR is an independent program currently administered out of the Georgia Bureau of Investigation (GBI). The program is funded by state general funds. There are five state-level staff who are responsible for providing training and technical assistance to the local review committees. Local teams have no paid staff.

Teams
Georgia has both state and local review teams which are mandated.

State Team:
The state team is called the Georgia Child Fatality Review Panel (GCFRP). The Panel is comprised of 17 members, which meets quarterly to oversee the county child fatality review process, report to the governor annually on the incidence of child deaths and recommend prevention measures based on the data. Panel members are appointed by the Governor or Lt. Governor, or are ex-officio members as state agency leaders.

Local Teams:
Georgia has 159 counties, and each county has its own CFR committee. The local committees have seven mandated agency members that are directed to meet within 30 days of a child’s death, and to submit their findings (i.e. the CFR report form) within 67 days of the death. Local committees are encouraged to invite additional agencies/organizations to the review meeting, as necessary. CFR policy also requires that a prevention advocate be a member of the local committee. The county coroner/medical examiner alerts the district attorney when a death has occurred, who initiates the review. Local committees are also encouraged to meet regularly, even if no deaths have occurred, to develop and review prevention efforts.

Reviews
Local CFR committees review all injury-related, sleep-related, and unexpected/suspicious deaths to children who are less than 18 years old. Local committees submit their reviews using the National Fatality Review Case Reporting System.

Purpose
The main purpose of Georgia’s CFR program is to prevent deaths. The mission of CFR is to serve Georgia’s children by promoting more accurate identification and reporting of child fatalities, evaluating the prevalence and circumstances of both child abuse cases and child fatality investigations, and monitoring the implementation and impact of the statewide child injury prevention plan in order to prevent and reduce incidents of child abuse and fatalities in the state.

Data
Standardized data reporting forms are completed for all reviews. Georgia participates in the National CDR Case Reporting System, and joined in 2009. Vital records from the state registrar are referenced as a form of quality assurance making sure that all appropriate deaths are being captured for review. State CFR staff review the accuracy and completeness of the case reports submitted by the local committees, and ensure data quality on an ongoing basis.

Annual Report
An annual report is produced and distributed to the Governor, Lt. Governor, the General Assembly, state child-serving agencies and members of the community. The Annual Report presents a descriptive analysis of the data collected in the previous year, and provides prevention recommendations from the local review committees. It is due on January 1st of each year.

Prevention Initiatives
Georgia’s CFR findings have influenced policy changes. Statewide changes have occurred in child protection policy in that all child maltreatment reports of children younger than one require a fully undressed exam by the CPS worker; the state crime lab has made child death autopsies a priority, with state law requiring autopsies for all children younger than seven; state law now requires graduated drivers licensing for teens; and safe sleep messaging is standardized across all state agencies. Many local community changes have occurred as a result of CFR including new traffic calming measures in areas where deaths have occurred, installation of water rescue equipment and usage instructions near natural bodies of water; mandatory emergency defibrillators in public parks where youth sports are played; and creation of an asthma prevention coalition in an area where multiple asthma-related deaths have occurred.

Local teams also have an increased understanding of team member’s roles, better communication and working relationships. Child death investigation teams have been formed to encourage collaboration and communication across multidisciplinary agencies throughout the investigation of a child’s death. Georgia was also selected as one of the first five state participants in the CDC’s SUID Case Registry pilot project, which focused on improving infant death scene investigations, review, and reporting in a multi-disciplinary setting.

Protocols
Currently there is a policy manual provided by the state CFR staff for the operating procedures of the local CFR committee. The CFR policy manual includes information on death notifications, review meetings, timelines, confidentiality, HIPAA protections and exemptions under the Public Health rule, and reporting procedures for coroners/medical examiners and the CFR chairpersons.

Training
The Georgia CFR Program offers training throughout the state. CFR offers child death investigation training for law enforcement. In addition, all local CFR members are required to receive training annually, state CFR staff travel to various jurisdictions each year. Each training is one full day, and includes workshops on investigation, review, reporting, collaboration, and prevention.

Last Updated: January 2019

Program Contact

Crystal Dixon-Washington
Child Fatality Review Unit Supervisor
Georgia Bureau of Investigation
Child Fatality Review Unit
3121 Panthersville Road
Decatur, Georgia 30034
Cell: (404) 326-2833 Cell
Desk: (404) 270-8717 Desk
Fax: (404) 270-8720
Email: Crystal.Dixon-Washington1@gbi.ga.gov

Website: https://dofs-gbi.georgia.gov/departments/medical-examiners-office/child-fatality-review-program

Tools

Hawaii

Program Description

Administration
In 1997, HRS 321, part 27 established the Child Death Review Program giving the Department of Health authority to conduct multidisciplinary and multiagency reviews of child deaths in order to reduce the incidence of preventable child deaths. The Department of Health and the Department of Human Services provide federal and state funds to staff the program. The Maternal Child Health Branch of the Hawaii Department of Health administers the CDR system. Emergency Services and Injury Prevention Services Branch is an active partner on the State CDR Council as well as local teams, and uses CDR findings to prioritize initiatives.

Teams
State Team: (Chairperson Kimberly Arakaki; Medical Consultant, Louise Kido Iwaishi, MD)
The State CDR Council is comprised of 20 agencies and meets quarterly. The Council does not review cases.

Local Teams:
The Local CDR Teams consist of five teams, representing Kauai, Big Island, Maui, Oahu and Military and meet as needed.

Reviews
Local CDR Teams conduct retrospective reviews of preventable deaths of children who are younger than 18 years old for deaths that occur in the state, according to established criteria for review.

Purpose
The main purpose of the Hawaii CDR program is to prevent deaths.

Data
The Hawaii CDR program has access to state vital statistics data for all child death cases. Vital statistics data is entered for all deaths to the National Fatality Review Case Reporting System. Standardized “CDR Case Report” forms are completed for deaths that receive a comprehensive local team review. The CDR Council Data Committee analyzes the data with Department of Health staff support.

Hawaii’s CDR Program has access to select state vital statistics. Vital statistics are used to generate a list of deaths annually and provides birth information for children less than three years of age.

Annual Report
Hawaii has produced three reports: the first was for the pilot period of 1996 and Summary reports for 1997-2000 and 2001-2006. The most recent summary report is available on the State of Hawaii website. Annual reports are currently required by the legislature and have been submitted in 2016 and 2017.

Prevention Initiatives
CDR prevention partners include Safe Sleep Hawaii, Keiki Injury Prevention Coalition (KIPC), Hawaii Suicide Prevention Task Force, DOH Injury Prevention and Control Program (IPCP) and others. For example, a Safe Sleep education campaign was initiated. Additionally, a suicide task force, under IPCP, has a state plan.

Protocols
A Child Death Review Policy and Procedure Manual.

Training
Previously, through the generosity of the Federal Community-Based Child Abuse Prevention grant and the National Center for the Review and Prevention of Child Death, Coordinated Infant Death Investigation training was provided in 2011 to promote a multi-disciplinary approach to death investigations. Stakeholders from the State of Hawaii, including City and County of Honolulu Medical Examiner staff, emergency medical personnel, law enforcement officials, child welfare workers, CDR members, and a representative from the Hawaii Safe Sleep Committee attended the training. Although CDR teams do not act as investigative bodies, team members apply best practices from the respective agency. This training helped to standardize the investigative and CDR process. CDR training was provided by the National Center in 2016 to all CDR teams.

Last Updated: February 2018

Program Contact

Alessandra Bezzi de Melo MBA BSN RN
Hawaii Child Death Review Coordinator
Hawaii Department of Health, Maternal and Child Health Branch
Child Death Review
741-A Sunset Ave.
Honolulu, HI 96816
Phone: 808-733-4182
Fax: 808-733-9032
Email: Alessandra.bezzi-demelo@doh.hawaii.gov

Tools

Hawaii Child Death Review Legislation

Idaho

Program Description

Administration
The current Idaho Child Fatality Review Team was established by executive order in 2012. The team operates under direction from the Governor appointed Task Force for Children at Risk. Review Team activities are funded and coordinated through the Department of Health and Welfare.

Teams
Idaho has a 20 member statewide review team. This is multi-disciplinary group of professionals representing law enforcement, coroners, child advocates, medical practitioners, attorneys, juvenile justice representatives, and Idaho Department of Health & Welfare employees.

Reviews
The Idaho Child Fatality Review Team reviews cases of children from birth through 17 years. They review child abuse deaths, preventable deaths and deaths due to external causes, unexplained or deaths with modifiable risk factors.

Purpose
The purpose of Idaho’s Child Fatality Review Program is to identify information and education which may improve the health and safety of Idaho’s children and to prevent instances of abuse and neglect.

Data
Data is collected for the review process from vital statistics records, autopsy reports, coroner’s reports, law enforcement reports, medical records, EMS records and child protection records.

Annual Report
An annual report will be submitted to the Governor’s Task Force for Children at Risk. The report includes conclusions and recommendations per category of death.

Last Updated: July 2019

Program Contact

Autum Ferris (she/her/hers)
Child Welfare Program Specialist: Safety and Independent Living
Bureau of Vital Records and Health Statistics
Idaho Department of Health and Welfare
P.O. Box 83720
Boise, ID 83702-5980
Phone: (208) 565-0995
Email: Autum.Ferris@dhw.idaho.gov

Website: http://idcartf.org/

Illinois

Program Description

Administration
The Illinois Child Death Review Teams were established in 1994 by statute (Section 515/1 et seq.). Illinois’s CDR Program has an annual budget of $107,500 and is funded by and housed out of the Department of Children and Family Services (DCFS). DCFS provides support in kind and contracts with Hoyleton Youth and Family Services for the Executive Director Position and a part time employee.

Teams
There are currently 9 teams across the state of Illinois. These teams are Aurora, Champaign, Cook County A, Cook County B, East St Louis, Marion, Peoria, Rockford, and Springfield. All of the teams cover several counties except for the Cook County teams because they cover the City of Chicago. Each team elects their own Chairperson and Vice Chairperson. The Chairperson and Vice Chairperson run the meeting and serve on the Illinois Child Death Review Teams Executive Council.

Executive Council Chairperson:
The Chairperson and the Vice Chairperson from each of the nine teams make up the Executive Council. The Executive Council meets monthly to review the recommendations made by each of the teams, every other month with the Director of the Department of Children and Family Services to discuss DCFS recommendations, and quarterly to discuss the procedures common to the Child Death Review Teams. The Executive Council serves as one of the panels for Illinois Citizen’s Review Panel.

Process
DCFS has a data sharing agreement with Department of Human Services. We receive information on all child deaths electronically from the Department of Human Services. This data is imported to our Child Death Review Database. The CDRT staff check to see if the child/ family had contact with the Department of Children and Family Services within the last year of the child’s death. If the child did have contact with DCFS then the child’s death is mandated for review. The appropriate team will review the child’s death. The teams are also allowed to review at their discretion, any child death that is sudden, unexpected, or unexplained.

Recommendations
After the review of the child death, the team decides if they can make a recommendation on the case. There are four types of recommendations a team can make:

Primary prevention, i.e., Get Water Wise, Supervise
DCFS, i.e., policy/ procedural change within the department
Other systems, i.e. contacting hospitals or coroners regarding policies
Case specific, i.e., concern for the surviving children

Response
A response feedback loop has been created between the Child Death Review Teams Executive Council and the Department of Children and Family Services. The Executive Council meets with the Department of Children and Family Services’ Director every other month. The Director discusses the recommendations with the Executive Council and decides to agree or disagree with the response from the Department of Children and Family Services’ Deputy Directors. There is a specific timeline that the Director must follow when responding to recommendations. According to legislation, the Director has 90 days to review and reply to recommendations made by a team. After he submits this reply to the Executive Council, he has 90 days to submit an additional report that details how the recommendation will be implemented by the Department. Within 180 days of the additional report a further report must be submitted by the Director to the Executive Council stating the specific changes within the Department that have been made in response to the recommendation.

Purpose
The purpose of the Illinois Child Death Review Teams is to reduce the number of preventable child deaths in Illinois.

Data
Standardized data reporting forms are completed for all reviews. Child Death Review Teams’ data is stored in a database and analyzed by the DCFS Research Center. The Illinois Child Death Review Teams have access to state vital statistics. State vital statistics are reviewed and sent on to regional teams.

Annual Report
Illinois produces an annual report. The report is distributed to the Governor, Legislators, Coroners, State’s Attorneys, Law Enforcement agencies, Team Members and others as requested.

Prevention Initiatives

The Child Death Review Teams’ findings motivate prevention activities in Illinois.

Get Waterwise…Supervise
The campaign is aimed at reducing deaths of children of all ages. The promotion of the statewide public awareness campaign on child drowning, Get Water Wise – Supervise continues to be widely circulated throughout the state of Illinois. A drowning prevention committee has been developed that includes representatives from the Child Death Review Teams Executive Council, DCFS, Department of Human Services, Prevent Child Abuse Illinois, the Red Cross and the Illinois Department of Public Health. The posters and brochures are available in both English and Spanish. The campaign carries a powerful message to parents and caregivers about the importance of adult supervision at all times when children are in and around water. Billboards and bus cards were developed and displayed for 6 weeks starting in May 2011. Billboards were placed in Quincy, Springfield, Decatur, and Effingham. Bus cards were placed in Springfield (100), Peoria (50), Danville (15), Urbana (75), Granite City (50), Arlington Heights (600), Carbondale (20), Rock Island (50), and Decatur (50). The billboard included a picture of a toddler in a bath tub with the following message:

1) “I left her in the bath for just a minute.” A minute is all it takes for a child to slip silently underwater while her caregiver leaves the room to answer the phone.*
*Drowning is the leading cause of accidental death for young children. The good news is that these tragedies can be prevented. Watch kids near water, and save a life.

Representatives from the committee also attend caregiver and kid friendly events to hand out these materials and educate the general public. Posters, brochures, coloring books, and PowerPoints are available at no charge.

Prevention of Bedsharing
The Illinois Child Death Review Teams Executive Council agreed to work with DCFS on developing a protocol to establish uniform procedures for investigating a death that may be attributed to unsafe sleeping conditions. The goal of the Executive Council’s participation in this process was to ensure that Child Protection Investigation Specialists, Intact Family Specialists, Permanency Specialists, and Purchase of Services Staff who are servicing families understand safe sleeping practices for infants, understand how to investigate a death that may have been caused by an unsafe sleeping practice, and understand the different ways deaths can be classified on a death certificate when an unsafe sleeping practice has contributed to the death. DCFS has developed this protocol and the Executive Council revised the protocol multiple times with input from DCFS. The Executive Council continues to work with DCFS on how to implement this protocol with DCFS staff.

The Child Death Review Teams Executive Council promote the Safe Sleep for Baby Campaign aimed at reducing infant deaths. The nine child death review teams continue to see many infant deaths related to the caregiver and infant bedsharing. DCFS workers currently distribute a safe sleeping brochure to families with infants receiving services. The brochure, Safe Sleep for Your Baby, from the National Institute of Child Health and Human Development, and, following the recommendations set forth by the American Academy of Pediatrics (AAP), urges caregivers to room share and not bed share with infants. Billboards were placed across the state with the message

Rock A Bye Baby ALONE in your CRIB,
Lying on your BACK, NO Pillows, No Quilts,
Sleep SAFELY Baby ALL the time.
Questions? Call 1.800.432.7437 (SIDS of Illinois, Inc. number)

The CDRT staff distribute information on all of the following for free: Care Enough to Call, Get Water Wise, Supervise, How well do you know lover (paramour safety), Safe Sleep for Your Baby, Never Shake a Baby, and No Shame, No Blame, No Names (Safe Haven Law). CDRT has partnered with SIDS of Illinois, Inc. to distribute information on topics including Safe sleep, Safe Crib, Tummy Time Tips & Tools, Safe Sleep for my Grandbaby, and SIDS and the Childcare Provider. These brochures are also free. All brochures listed are offered in English and Spanish.

Protocols
Illinois recently updated the Illinois Child Death Review Teams Protocol and Best Practices for the Multidisciplinary Review of Child Deaths in August 2015.

Training
The Illinois Child Death Review Teams Executive Council and the Illinois Department of Children and Family Services host a symposium every year for all team members. The symposium updates the knowledge and the skills of all members. It also offers a networking opportunity for the different teams.

Last Updated: January 2017

Program Contact

John Schweitzer
Child Death Review Manager
Illinois Department of Children & Family Services
800 Roosevelt Road, Suite D-10
Glen Ellyn, IL 60187
Phone: 630-790-6800
Email: John.Schweitzer@illinois.gov

CDRT Executive Director:
Tamara Skube
Illinois Department of Children & Family Services
1124 N. Walnut
Springfield, IL 62703
Phone: 217/ 786-6846
Fax: 217/557-4648
Email: Tamara.Skube@illinois.gov

Chairperson of the CDRT Executive Council:
Joan Pernecke
Email: joan.pernecke@cookcountyil.gov

Vice Chairperson of the CDRT Executive Council:
Daniel J. Cuneo
Email: dcuneo@charter.net

Website: http://www.illinois.gov/dcfs/aboutus/policy/Pages/com_communications_CDRT.aspx

Tools

Indiana

Program Description

Administration
On July 1, 2013, a new Indiana law (IC 16-49) went into effect, requiring child fatality review teams in each county, with coordination and support for these teams to be provided by the Indiana State Department of Health (ISDH). Prior to this, the local child fatality review teams fell under the auspices of the Indiana Department of Child Services (DCS) and were required in each of the 18 DCS regions. IC 16-49 also required that a coordinator position be created under the ISDH to help support and coordinate the local teams and Statewide Child Fatality Review Committee–whose members are appointed by the Governor.

The prosecuting attorney in each county is required by this new legislation to establish a Child Fatality Committee whose membership includes: the prosecuting attorney or their representative, the county coroner or deputy coroner, and representatives from the local health department, DCS, and law enforcement. The Child Fatality Committee is responsible for selecting members to serve on the Local Child Fatality Review (CDR) Team and determining whether to establish a county child fatality review team, or enter into an agreement with another county or counties to form a regional child fatality review team.

Teams
State Team: The Statewide Child Fatality Review Committee is comprised of 15 members who are appointed by the Governor, and several ad hoc members who serve at the request of the Committee. The Statewide Committee meets monthly, serving as a consulting body to assist the efforts of the local teams and can assist with, or conduct, individual case review at the request of a local team or the DCS Ombudsman.

Local Teams: Indiana has 66 county and regional teams representing 89 of the 92 counties. Each local CFR team will be made up of a coroner/deputy coroner, a pathologist, and pediatrician or family practice physician, and local representatives from law enforcement, the local health department, DCS, emergency medical services, a school district within the region, fire responders, the prosecuting attorney’s office, and the mental-health community.

Reviews
Local teams are required to review all deaths of children under the age of 18 that are sudden, unexpected or unexplained, all deaths assessed by DCS, and all deaths that are determined to be the result of homicide, suicide, accident, or are undetermined.

Purpose
The Indiana CFR Program attempts to better understand how and why children die, takes action to prevent injury, disability, and death and improves the health and safety of our children.

Data
Indiana utilizes the Case Reporting System administered by the National Center for the Review and Prevention of Child Deaths. Case report forms are completed for all reviews as required by statute. The Indiana CFR has access to injury data, maternal and child health data, and vital statistics information.

Annual Report
Local teams are required to provide an annual report to the Statewide Child Fatality Review Committee, who will then endeavor to identify trends and inform efforts to implement effective statewide prevention strategies. The Statewide Committee is required to submit an annual report to the Indiana legislative council, Governor, DCS, ISDH, and the Commission on Improving the Status of Children in Indiana.

Prevention Initiatives
Indiana CFR findings have motivated local prevention such as bumper pad /sleep sack exchange programs, infant safe sleep education and crib give-aways, infant safe sleep media campaigns, water safety education, suicide prevention and ATV safety initiatives.

Program and policy changes at the regional and state levels have also been implemented as a result of CFR. Some regional hospitals have stopped using blankets in their labor/delivery and NICU areas to ensure the presentation of a consistent safe sleep message. As a result of case review by the Statewide Committee, legislation was passed requiring ladder locks to be sold with above ground pools to help prevent access by unsupervised children.

Training
Training for the local teams and Statewide Committee is organized by the state CDR program coordinator and local partners.

Last Updated: January 2019

Program Contact

Jamie Smith
State Child Fatality Review Program Coordinator
Indiana State Department of Health
2 North Meridian Street
Indianapolis, IN 46204
Phone: 317-645-8422
Fax: 317-234-2995
Email:JamiSmith@isdh.in.gov

Website: http://www.in.gov/dcs/

Iowa

Program Description

Administration
The State of Iowa Child Death Review Team was established in 1995 by Statute, 641-90.1 et seq. The Team had an initial annual budget of $28,000. Funding for the program came from the Department of Public Health’s MCH Block grant ($8,000) and state general funds ($20,000). Funding is year-to-year. In the spring of 2009, the Iowa Office of the State Medical Examiner (IOSME) was assigned the coordination of the team with no funding or staff due to state budget cuts. The IOSME currently has one fulltime and two part-time staff members assigned to assist the Team Coordinator with case review and team management.

Teams
Iowa has a state review team.

State Team Chairperson: Meghan Harris, Ed.D.
The team is comprised of 14 official members and six state department liaisons. The team meets at least four times per year. The State Team has participated in legislative hearings, educational presentations and published articles in professional journals.

Reviews
The Iowa CDR team reviews deaths of children 17 and under.

Purpose
The purpose of Iowa’s CDR Program is education and prevention.

Data
Standardized data reporting forms are completed for all reviews. The collection of data is not required by legislation or policy, but is needed for their annual report. Iowa CDR has access to state vital records. Vital records (birth and death certificates) are used to identify child deaths and for background checks. CDR data are stored on a computer file and in hard copy for three years. The data are analyzed using frequency distributions by manner and cause.

Annual Report
Iowa does produce an annual report. The report is on the Iowa Office of the State Medical Examiner’s website. Recommendations are sent to the Governor and legislature. The report is distributed to the Governor, legislature, state agencies, law enforcement and county attorneys.

Prevention Initiatives
Iowa CDR efforts have influenced change. Statewide examples of this include an influence on proposed legislation, coordination of CDR data with the Iowa SIDS Foundation and changes in the length of sentences for criminals who kill a child. Examples of how CDR findings have motivated prevention activities include the distribution of SIDS brochures, posters and videos to child care providers and educational materials on bed-sharing. This effort has been evaluated for effectiveness. Evaluation efforts consisted of a hospital survey that measured data from 2001 through 2002. The data showed that in 2001, nine out of 93 hospitals placed babies in their newborn nurseries to sleep on their backs and in 2002 (after brochures had been distributed), nearly all reporting hospitals placed babies on their backs except for those with medical reasons requiring a different sleep position.

Protocols
Iowa CDR has confidentiality and child death investigation protocols in place.

Training
Iowa CDR provides training on child abuse and Sudden Infant Death Syndrome. Funding is not currently available.

Last Updated: February 2018

Program Contact

Analisa Pearson
CDRT Coordinator
Iowa Department of Health and Human Services/Iowa Office of the State Medical Examiner
2250 S. Ankeny Blvd.
Ankeny, IA 50023
Phone: (515) 418-8122
Email: analisa.k.pearson@hhs.iowa.gov

Website: www.iosme.iowa.gov

Tools

Kansas

Program Description

Administration
The State Child Death Review Board (SCDRB) was created by the Kansas Legislature in 1992 and is administered by the Kansas Attorney General’s Office. The SCDRB is a ten-member multi-disciplinary agency whose appointments are defined by statute, K.S.A. Supp. 22a-243 et seq. There are two staff persons within the office. The SCDRB serves as one of the State’s Citizen Review Panels.

Teams
Kansas has one SCDRB which is mandated by state law. The SCDRB also serves as a member of:

Midwest Regional Child Death Review (CDR) Coalition
National Child Death Review Panel
Safe Kids Kansas
CAPTA-Intake to Petition
CAPTA-Custody to Transition
Kansas Maternal Child Health Coalition
Prescription Drug Policy Academy Workgroup

State Team Chairperson: Melissa Johnson, JD, Assistant Attorney General.

Reviews
The SCDRB meets monthly to examine the circumstances surrounding the deaths of all Kansas children aged birth through 17 years, as well as children who are not residents but die in the state. Typically the SCDRB is alerted of a death when they receive birth/death certificates from the Kansas Department of Health and Environment Vital Statistics Department. The SCDRB has a working relationship with other state vital statistics departments to receive death certificates as needed when a Kansas child passes away in another state.

To ensure a coordinated response that fully addresses all systemic concerns surrounding child fatality cases, the Kansas Legislature granted the SCDRB authority to obtain all relevant records. K.S.A. 22a-244(b) provides that the Board shall have access to any necessary records related to the child. All records provided to the Board remain confidential. When all information has been obtained, a case is assigned to a SCDRB member who is responsible for reviewing the information and reporting the findings to the entire Board during the monthly meeting. A determination of true cause and preventability is made during the meeting.

Purpose
The purpose of the SCDRB is to determine the number of Kansas children who die annually, describe trends and patterns of child deaths, identify risk factors, improve information gathering and communication among agencies, and develop prevention strategies in order to lower the number of child deaths.

Data
The SCDRB determines the number of children who die, how they died, and reports annually on what the data shows.

Annual Report
Kansas produces an annual report that includes its findings, recommendations for improving child protection, and suggestions for modifying statutes, rules, regulations, policies, and procedures. The Board is required to provide the annual report to the Kansas Legislature and the Governor.

Prevention Initiatives
CDR efforts have influenced policy change and findings have motivated prevention activities including:

A focus on motor vehicle crashes — which is the leading cause of unintentional injury deaths for Kansas children;
An increase in fines for non-compliance with child passenger safety laws;
More adherence to enforcing the child safety restraint law that requires youth younger than 18 seated anywhere in the vehicle to use age appropriate safety restraint systems;
Improving women’s preconception health to lower infant mortality
Strengthening partnerships for public education purposes
Suicide Prevention training in Kansas schools
Statewide training for Law Enforcement, Coroners, Pathologists, and Child Protection Workers

Protocols
The SCDRB has protocols for meetings, confidentiality, and child/infant death investigations.

Training
Kansas provides training as needed.

Last Updated: February 2018

Program Contact

Sara Hortenstine
State Child Death Review Board
120 SW 10th Ave. 2nd Floor
Topeka, Kansas 66612
Phone: 785-296-7970
Fax: 785-296-7796
Email: sara.hortenstine@ag.ks.gov

Website: http://ag.ks.gov/about-the-office/affiliated-orgs/scdrb

Tools

Kentucky

Program Description

Administration
Established in 1996 per statute (section 211.680 et seq.), Kentucky’s Child Fatality Review Program works to identify child deaths for review and evaluation to inform program policy and prevention efforts. The CFR program is organizationally located in the Maternal and Child Health (MCH) Division, Department for Public Health. Kentucky is part of the Southeast Coalition on Child Fatalities.
MCH Title V Block Grant provides funding for the annual budget of $418,500. Kentucky has a SUID case registry funded by the Sudden Unexpected Infant Death (SUID) Case Registry Grant. Local health departments receive an allocation of $1,000 per county to assist with costs of child death reviews and prevention activities. Staffing for the program is

Full time nurse consultant inspector
Full time administrative/data entry assistant

Additional program support is provided from the Chief Medical Examiner, an epidemiologist and the SUID case registry program

Teams
Kentucky has both state and local teams, which are not mandated.

State Team Chairperson: Dr. Christina Howard
The team is comprised of approximately 30 additional members representing diverse agencies and meets every other month to discuss prevention activities and initiatives.

Local Teams:
The chairperson at the local level is the County Coroner. Kentucky has 120 counties. One hundred and five counties have teams conducting child death reviews for approximately 74% of the counties, with two additional counties preparing. Fifteen additional counties are actively preparing local review teams. Teams are comprised of six to ten multidisciplinary members. Technical support is provided for local teams by the State CFR nurse consultant/inspector.

Reviews
Local teams review coroner cases for children under 18 years of age. Any cases suspicious of abuse or neglect are forwarded for additional review to the Kentucky Child Death Fatality and Near Fatality External Panel. The Kentucky State Sudden Unexpected Infant Deaths (SUID) Team reviews SUID cases that are not reviewed at a local level.

Purpose
The goal of the Kentucky Department for Public Health’s Child Fatality Review (CFR) Program is ultimately to decrease child deaths through prevention efforts. Review of aggregate data from vital statistics is used to identify trends and emerging issues in preventable fatalities. Using data driven best practice programming, the goal is to reduce child death rates by:

Facilitating the development of local child fatality review teams, which may include training opportunities and technical assistance;
Developing and distributing model protocols for local child fatality review teams that investigate child fatalities;
Reviewing and approving local protocols prepared and submitted by local teams;
Analyzing data regarding child fatalities to identify trends, patterns and risk factors;
Evaluating the effectiveness of adopted prevention and intervention strategies;
Making recommendations regarding state programs, legislation, administrative regulations, policies, budgets, and treatment and service standards, which may facilitate the development of strategies for the prevention and reduction of the number of child deaths; and
Promoting services and resources for bereavement to families and communities through the local health departments.

Data
Standardized data reporting forms are completed for all reviews as required by state statute. Electronic and hard copy data files are stored securely. The CFR program has access to vital statistics records including electronic transmission of data from the electronic death registration system, coroner’s reports, and other sources.

Annual Report
Kentucky produces an annual CFR report based on the calendar year that is data driven and highlights prevention efforts from stakeholders. The report is distributed to selected government officials, Department for Public Health staff, local health departments, coroners and others upon request.

Prevention Initiatives
In 2019, a total of 99.4% of child fatalities identified as reviewable were reviewed. CFR findings influence policy changes in Kentucky. Statewide examples include booster seat and graduated driver’s license legislation and the provision of educational materials to prevent pediatric abusive head trauma to birthing hospitals in Kentucky. CFR findings were pivotal in the development of a Safe Sleep campaign (safesleepky.org).

Protocols
Kentucky has protocols in place including confidentiality, and recommendations for the composition of local teams. The Kentucky CFR program recommends that all teams follow the recommendations from the National Center for Child Death Review.

Training
Kentucky CFR coordinates all program oversight and provides technical support and training to local health department staff and coroners. Training is available upon request from other agencies and organizations.

Last Updated: January 2019

Program Contact

Matt Belcher, MPA
Kentucky Department for Public Health
Maternal and Child Health Division
275 East Main Street, Mail Stop HS2W-A
Frankfort, Kentucky 40621
Email: matt.belcher@ky.gov

Website: http://chfs.ky.gov/dph/mch/cfhi/childfatality.htm

Tools

Kentucky Child Fatality Review Legislation

Louisiana

Program Description

Administration
The Louisiana State Child Death Review Program (CDR) was established in 1992 by the Louisiana Legislature, and in 2001, local Child Death Review teams were established in each of Louisiana’s nine Office of Public Health regions. The Louisiana CDR Program functions under the auspices of the Louisiana Department of Health, Office of Public Health’s Bureau of Family Health. MCH Title V Block Grant funds support the Local and State CDR.

Teams
Louisiana has both state and local CDR teams. The state level team is mandatory and local teams are permissive. Citizens serve on both the state and local level teams.

State Team: (Panel Chairperson- State Health Officer)
The Louisiana State CDR Panel is a multi-disciplinary panel of 25 members of Louisiana state and non-governmental agencies and organizations, as defined by Louisiana legislation R.S 40:2019. State CDR review findings and recommendations that result from local review in order to take state-level actions that prevent future injury or fatality, and to improve the health and safety of Louisiana’s children. The State team meets quarterly and must submit an annual report of case review findings to the Louisiana legislature.

Local Teams: (Panel Chairperson(s) – Regional Maternal and Child Health Coordinator)
In 2001, Local Child Death Review teams were established in each of Louisiana’s nine Department of Health Administrative Regions. Core panel members include representatives from the following agencies or professions: law enforcement, child protective services, District Attorney/prosecutor, medical examiner/coroner, public health, pediatrician or other family health provider, and emergency medical services. The Local CDR Panels are tasked with reviewing reports of all unexpected deaths among children 14 years and younger to better understand how and why children die. Based on their reviews, local teams are responsible for making and implementing recommendations for child safety and injury prevention, in their respective regions. Further, findings and recommendations are shared with State CDR for further action, if necessary.

Reviews
Louisiana CDR case reviews are retrospective. Death certificates on all children less than 15 years of age are received, and case selection for panel review is based on the age of the child (0 through 14 years), manner (unintentional) and cause of death (unexpected, unclear, unexplained/undetermined, or of a suspicious circumstance). Investigative reports, including autopsies and death scene investigative reports, are requested for case reviews of unexpected deaths. State CDR reviews select unexpected child deaths, while local CDR teams review all unexpected deaths in children under 15. After complete review of each case, prevention recommendations are made by the State and/or Local CDR teams, and the recommendations and case review findings are then disseminated to agencies and groups that can use this information to prevent future deaths. Case reviews are not performed on child deaths due to natural causes, child deaths under investigation by law enforcement, or cases pending/active criminal prosecution. Louisiana also has Fetal Infant Mortality Review (FIMR) and Pregnancy-Associated Mortality Review programs.

Purpose
The Purpose of the State CDR is to perform multi-disciplinary, multi-agency reviews of unexpected, unintentional child deaths of children under 15 years of age to develop a greater understanding of the causes of child deaths, preventing such deaths, and of the gaps in services and, thereby, reduce the incidence of injury and death among infants and children.

Data
The three primary CDR data sources for Louisiana are: death certificates from Louisiana Center for Health Statistics and Vital Records, investigative case reports (including the national, standardized Sudden Unexpected Infant Death Investigation reporting form), and the CDR database. The CDR case report used to collect data on child deaths in Louisiana is a standardized case report form provided by the National Center for Child Death Review. The case reports are completed by both state and local panel members. Regional Maternal and Child Health Coordinators then enter the data into the CDR database. The Bureau of Family Health’s Mortality Epidemiologist performs data analysis.

Annual Report
Louisiana is required to produce an annual report. The 2013-2015 CDR report is the most recent completed report. The report is submitted to the Governor and Louisiana legislators, disseminated to state agencies, CDR team members, partners, and is made available to the general public.

Prevention Initiatives
CDR findings have influenced the development and implementation of educational and prevention initiatives in Louisiana. Statewide and local examples of these initiatives include:

Revisions to Child Death Investigation law
Development of a Safe Sleep Subcommittee dedicated to preventing sleep related deaths in Louisiana
Development of a Water Safety Subcommittee dedicated to preventing drowning deaths in Louisiana

Protocols
Louisiana’s CDR Program maintains protocols for confidentiality, investigative case reporting, case reviews, and bereavement support to families.

Training
Professional development among the local CDR Program coordinators continues to be a priority. Over the past year state and local Maternal and Child Health Coordinators completed various trainings/certification courses, including Crucial Conversations, Story Telling Workshops, and have planned anti-oppression and facilitation trainings planned for 2018

Last Updated: January 2019

Program Contact

Sara Dickerson
Maternal & Child Health Coordination Manager
Bureau of Family Health
Louisiana Department of Health
1450 Poydras Ave., Suite 2032
New Orleans, Louisiana 70112
Office: 504-568-3504
Email: Sara.Dickerson@la.gov

Kristen Sanderson
Injury Prevention Coordination Manager
Bureau of Family Health
Louisiana Department of Health
1450 Poydras Ave., Suite 2032
New Orleans, Louisiana 70112
Email: Kristen.Sanderson@la.gov

Tools

Louisiana Child Death Review Legislation

Maine

Program Description

Administration
The Maine Child Death and Serious Injury Review Panel was established by statute (Title 22, section 4004) in 1992. The panel is housed through the Department of Health and Human Services. There are two staff members for the Panel which is funded by the Children’s Justice Act.

Teams
Maine has a state level review system. Maine joined other New England states to form a consortium of Northern New England child fatality review teams. Additionally, the coordinator for the Panel coordinates two related Panels, the Child Abuse Action Network and the Citizen’s Review Panel.

State Team Chair and Vice chair: Mark Moran, LCSW and Lawrence Ricci, MD
The panel consists of the following members: Chief Medical Examiner, pediatricians, public health nurses, forensic and community mental health clinicians, law enforcement officers, departmental child welfare staff, district attorneys, domestic violence specialist and criminal or civil assistant attorneys general.

Cases are identified for review from a variety of sources. Some come from public health nursing, social services, law enforcement and sometimes psychologists.

The Panel meets every month for approximately three hours. All panel members are given the time to attend the review meetings by their public or private sector employers. Panel members volunteer their time to read the voluminous case record materials before each case review.

Reviews
The panel reviews cases of suspected child abuse and neglect as well as adolescent suicides and SUID. In addition, an infant mortality subgroup is looking into infant mortality in Maine. Cases for review are identified by pediatricians and Children’s Protective Services. The Panel can subpoena records for the review process. Team information is not subject to discovery. Deaths to children less than 18 years old are reviewed.

Purpose
The purpose of the panel is to recommend to state and local agencies methods of improving the child protection system, including modifications of statutes, rules, policies and procedures and to promote public health and prevent future tragedies.

Data
Standardized data collection forms collection forms are completed on each case reviewed. This is not required by statute. Data is stored on disc. The panel does have access to state vital statistics. The staff person to the panel utilizes DHS Vital Records to collect/verify family vital records information on each case reviewed.

Annual Report
Aggregate data collected by the panel is utilized in periodic public reports published by the Panel. Additionally, each case review results in a confidential Executive Summary for the DHS commissioner. This summary contains findings and recommendations. The Department responds to the recommendations in writing.

Prevention Initiatives
The panel findings have motivated prevention activities in the state including the “Never Shake a Baby” public awareness campaign and the Period of Purple Crying Campaign. The team also recommended an amendment to the Maine midwifery law based on a review of home birth fatality. A future public service campaign will focus on safe sleeping practices including the potential hazards of adults co-sleeping with infants. Additionally, the Panel has worked to develop scene investigation protocol with the Medical Examiner, State Police and Child Welfare.

Protocols
Maine’s Child Death and Serious Injury Review Panel has meeting and confidentiality protocols in place.

Training
Training is not offered. However, individual panel members attend training and bring the information back to the team. Members have also said that one of the important aspects of each review is the “seminar” nature of information/collaboration among the panel members, who have wide-ranging areas of expertise, which they bring to each case review’s discussion. Individual panel members also provide training on child welfare related issues in various statewide and national venues.

Last Updated: January 2017

Program Contact

Jenna Joeckel, LMSW-cc
CAPTA/CJA Panels Coordinator
Department of Health and Human Services
Office of Child and Family Services
38 Prescott Drive
Machias, ME 04654
Phone: (207) 557-1876
Email: Jenna.L.Joeckel@maine.gov

Mark Moran, LCSW
Chair, Child Death and Serious Injury Review Panel
Amanda Brownell, M.D.
Vice Chair, Child Death and Serious Injury Review Panel

Website:http://www.childabuseactionnetwork.com/Related-Panels/child-death-and-serious-injury-review-panel-29.html

Tools

Maine Child Death Review Legislation

Maryland

Program Description

Administration
Maryland Senate Bill 464 created child fatality review, state and local Citizens Review Panels and the state CAN Council. CFR is mandated but not funded. The program was established by statute (Section 5-701 et seq.) in 1999. It is housed out of the Maternal and Child Health Bureau (MCHB), Maryland Department of Health (MDH). There is one employee at the state level. MCHB also administers the Fetal Infant Mortality Review (FIMR) program.

Teams
Maryland has both a state and local CFR teams which are mandatory in each county. CFR also serves as one of the three CAPTA Citizen Review Panels, the others being the State Council on Child Abuse and Neglect and the State Board of the Citizen’s Review Board for Children.

State Team Chairperson: Richard Lichenstein, MD
There are 25 members on the Maryland State Child Fatality Review Team. The Governor appoints the members which include 11 citizens with expertise or interest in child safety or welfare, 12 representatives from state agencies and two pediatricians who are members of the American Academy of Pediatrics. Meetings are held quarterly. The State Team created a policy manual of guidelines to assist local teams with the child fatality review process.

Local Teams:
Local CFR teams are mandated to be multi-agency and multi-disciplinary. Maryland has 23 county based review teams and one city team (Baltimore). Teams conduct retrospective/periodic review of cases. Local teams advocate at the local level through such avenues as letters to the editor and recommendations to agencies. They also identify education and training needs at the local level.

Reviews
In Maryland, local CFR teams review deaths to children ages 0-17. (The State Team only rarely reviews cases.) Local teams may elect to review deaths up to 21 years of age. Teams review all causes of deaths from cases received from the Office of the Chief Medical Examiner (unusual and unexpected deaths).

Purpose
The purpose of the Maryland CFR Program is prevention of child deaths.

Data
Maryland participates in the electronic data system made available to all states by the National Center for the Prevention and Review of Child Deaths (NCPRCD). Local teams enter data from case reviews directly into the data system so data summaries are easier to obtain.

Annual Report
Maryland CFR produces an annual report – which reviews the efforts, findings and recommendations of the State and local CFR teams. The report is issued to the Governor, the General Assembly and state and local CFR members.

Prevention Initiatives
CFR findings have motivated prevention activities in the areas of motor vehicle crashes, SUIDs, homicides, suicides and natural means.

Training
The State CFR Team conducts an annual meeting to provide training and education to local CFR team leadership. In 2017, the annual meeting covered a wide variety of topics, including a presentation on Data Quality Control and Improvement. Additionally, there was a training exercise titled “Turn the Curve,” which is a results-based accountability exercise that allows groups to work on turning the curve on specific indicators such as child, adult, family and community well-being. The Baltimore City CFR Coordinator led a presentation on Essentials for Childhood. Lastly, Ms. Cheri Wilson; a nationally recognized diversity and inclusion, cultural and linguistic competence, and health equity subject matter expert, gave an in-depth presentation on intrinsic bias.

In February 2018, the State CFR Coordinator began quarterly calls with local teams. These calls will be used to assess potential technical assistance needs and develop quality assurance protocols.

Last Updated: July 2019

Program Contact

Thuy Nguyen
Infant Health Program Coordinator
Maternal and Child Health Bureau
Prevention and Health Promotion Administration
Maryland Department of Health
Maternal and Child Health Bureau
201 W. Preston St., Room 309
Baltimore, MD 21201
Email: thuy.nguyen@maryland.gov

Website: https://phpa.health.maryland.gov/mch/Pages/cfr-home.aspx

Tools

Massachusetts

Program Description

Administration
The Massachusetts CDR program was established by statute (MGL C 38 Section 2) in 2000. It is an unfunded mandate, but some resources for state activities have been identified through two federal sources, the MCH Block grant and the EMS for Children grant. The state team is jointly convened by the public health department and the office of the chief medical examiner; administrative and operations functions are within the public health department. There are four Department of Public Health employees providing in-kind support and a .5 FTE dedicated Coordinator position.

Along with the CDR program, Massachusetts Department of Public Health also administers the EMS for Children project.

Teams
Massachusetts has both state and local teams which are mandatory. State statute defines team membership at both the local and state level but does not limit it. Massachusetts is a member of the New England Regional CDR Coalition.

State Team Chairperson: Henry Nields, MD, PhD, Chief Medical Examiner
According to statute, the state team falls under the jurisdiction of the state medical examiner. The team is comprised of 16 statutory members and meets every other month. The state team is co-chaired by Leonard Lee, Director of the Division of Violence and Injury Prevention at the Department of Health.

Local Teams:
According to statute, the local teams fall under the jurisdiction of the District Attorney Offices. There are 11 teams, each comprised of 10-20 members. The teams are mandated to meet at least quarterly, the larger districts meet more frequently.

The local recommendations are forwarded to the state team for review and development of action steps.

Reviews
The Massachusetts CDR team reviews deaths to children under the age of 18. Some of the larger teams do not review deaths of premature infants. There are three city-based Fetal Infant Mortality Review (FIMR) in the state that examine many of these cases. A statewide Review of Infant Mortality process has been initiated to provide higher quality reviews of medically-related infant deaths.

Purpose
The purpose of the Massachusetts CDR program is prevention, investigation, to facilitate interagency networking and collaboration and to produce recommendations for changes that will protect the health and safety of children. The program has always had a focus on public health.

Data
Several of the local teams are utilizing the National Center’s web-based reporting system for data collection. In addition, all teams are asked to complete a one page data form on all deaths that undergo a local team review. This information is entered into an ACCESS database and is used for monitoring the number and types of reviews completed throughout the state.

Massachusetts CDR has access to state vital statistics and uses the information in preparing an annual report. Additionally, the Office of Vital Statistics sends copies of death certificates to the State Medical Examiner Office which then forwards them to the local teams.

Annual Report
Massachusetts does produce an annual report. The report is distributed to state and local team members, legislators, interested parties, EMS providers and public health officials.

Prevention Initiatives
Massachusetts CDR implemented infant/child death scene investigation protocols and the distribution of safe sleep materials. MA CDR worked in conjunction with the Department of Elementary and Secondary Education to develop a memorandum for public schools that have public swimming pools located in them. MA CDR is also examining methods to enhance window fall and drowning prevention in Massachusetts.

Protocols
Massachusetts has an optional letter for local teams to use in requesting information for the review process. The State Team has provided recommended guidance/protocols for Local Teams and has developed standard processes for its own meetings.

Training
Massachusetts CDR does provide training. In the past, EMS-C has made funding available for an annual conference – the most recent of which was held in March 2013. The CDC Core VIPP Grant funds were also available to use for the annual CDR conference in 2016. However, funding for this work will become more problematic in the current fiscal environment.

Last Updated: January 2017

Program Contact

Bekah Thomas
Child Fatality Review Coordinator
Office of the Child Advocate
One Ashburton Place (Room 1101)
Boston MA 02108-4619
Phone: 617-645-9060
Email: bekah.thomas@state.ma.us

Tools

Massachusetts Child Death Review Legislation

Michigan

Program Description

Administration
The Michigan Child Death Review Program was established by statute (Section 722.627b) in 1997. The program has an annual budget of $639,209 and is funded by Michigan Department of Health and Human Services. CDR is managed by the Michigan Public Health Institute (MPHI). Funding for the program is on a three-year contract cycle. On the state level, 4.3 full-time employees staff the program. There are no paid positions at the local level.

Teams
Michigan has 77 county-based review teams and a state-level advisory team.

State Team Chairperson: Colin Parks, CPS Program Office, Department of Health and Human Services
The team consists of 18 members and meets quarterly. They are responsible for reviewing the findings from the local teams and issuing an annual report with recommendations to the governor and legislature. Members of the Michigan Child Death State Advisory Team also serves as the Citizen Review Panel on Child Fatalities with additional ad hoc membership.

Local Teams: (Chairperson – varies)
There are 83 counties in Michigan, all of which participate in child death review. Some counties have regional teams, consisting of two or more counties. Michigan has 77 local-level child death review teams. Frequency of meetings varies by county.

Reviews
Most of the local Michigan CDR teams review deaths that occur to children age 18 and under. Some only review through age 17. Teams in more populous counties may only review those deaths that fall under the jurisdiction of the medical examiner.

Purpose
To improve our understanding of how and why children die, to demonstrate the need for and to influence policies and programs to improve child health, safety and protection and to prevent other child deaths.

Key Objectives
1. The accurate identification and uniform reporting of the cause and manner of every child death.
2. Improved communication and linkages among agencies and enhanced coordination of efforts.
3. Improved agency responses to child deaths in the investigation and delivery of services.
4. Improved criminal investigations and improved response of the criminal justice system to child homicides.
5. Implement standardized statewide child death investigative protocols.
6. The identification of needed changes in legislation, policy and practices; and expanded efforts in child health and safety to prevent child deaths.

Data
Michigan is participating in the data collection project with the National Center for Fatality Review and Prevention. Case report forms are completed for all reviews, which is not required by state statute or policy. Michigan CDR has access to state vital statistics and uses that information to assess overall child death rates, supplement the CDR data in an annual report, and to respond to data requests. Data is stored electronically in SPSS and is analyzed for qualitative and quantitative information.

Annual Report
Michigan produces an annual report, as required by state statute. The report is distributed to the governor, state legislators, local team members, state agencies, other state child fatality review programs and others as requested.

Prevention Initiatives
CDR findings have led to many local prevention activities such as water safety initiatives, roadway/signage improvements, suicide prevention, infant safe sleep education campaigns, child safety equipment give-a-way programs and others.

CDR findings have also influenced program and policy changes at a state level. Changes include development of a State Suicide Prevention Plan, State Infant Safe Sleep Campaign, revisions of child care licensing rules, improved child passenger safety laws, graduated licensing provisions, the Birth Match program and many other improvements to the child protection system.

Protocols
Michigan has a variety of protocols in place including confidentiality, security and privacy, child death investigation and CDR meeting process.

Training
Training is provided on an annual basis for local review team members and is funded through program monies. Regional coordinator meetings are held annually, in a number of locations throughout the state. Additional trainings have occurred when funding sources have been available, and have covered topics such as death scene investigation, suicide prevention, and abusive head trauma.

Last Updated: January 2019

Program Contact

Heidi Hilliard
Michigan Public Health Institute
2465 Woodlake Circle, Suite 100
Okemos, MI 48864
Phone: 517-324-7331
Fax: 517-324-7365
Email: hhilliar@mphi.org

Website: https://mifrp.org/

Tools

Reports

Child Deaths in Michigan: Reports

Minnesota

Program Description

Administration
Minnesota’s Child Mortality Review Program was established in 1989 by legislation. The program is federally funded by the Child Abuse Prevention and Treatment Act and state funds. In 2015, the Minnesota Legislature enacted a new statute that requires the Department of Human Services to lead an on-site review of all fatalities and near fatalities caused by maltreatment, and those that occur in licensed facilities and are not due to natural causes. The Minnesota Department of Human Services, Child Safety and Permanency Division has authority to conduct child death and near death reviews under state statute. Four state employees staff the program.

Teams

Minnesota has both state and local teams.

Systemic Critical Incident Review Process led by the Department (Kelly Knutson – Quality Assurance Supervisor)

The Department has been working with Collaborative Safety, LLC, an organization out of Tennessee, to implement a trauma-informed, robust and scientific systemic critical incident review process for child fatalities and near fatalities that are due to maltreatment or that occur in licensed facilities and were not due to natural causes. The review process utilizes components from the same science used by other safety critical industries, including aviation and health care. The approach moves away from blame and toward a system of accountability that focuses on identifying underlying systemic issues to improve complex social systems such as Child Welfare.
This review process takes a systemic approach that departs from surface level understandings of how systems fail and seeks out the complex interplay of systemic factors. Collaborative Safety supports agencies/systems to develop a proactive response to critical incidents and a responsive system dedicated to learning. The Collaborative Safety Model currently being implemented, engages local and state agency leadership, frontline staff, and other key child welfare stakeholders on safety science principles, supporting safety advancement and system change.

Collaborative Safety’s founders Dr. Scott Modell and Noel Hengelbrok were referred to as pioneers in applying safety science to the field of child welfare by the Federal Commission to Eliminate Child Abuse and Neglect Fatalities. The Commission to Eliminate Child Abuse and Neglect Fatalities (CECANF) was established by the Protect Our Kids Act of 2012, which garnered broad, bipartisan support in the House, passed the Senate unanimously, and was signed by President Barack Obama on January 14, 2013. Its mission was to develop a national strategy and recommendations for reducing fatalities across the country resulting from child abuse and neglect. Both Modell and Hengelbrok were asked to present to the commission on Tennessee’s Child Death Review Process and how Safety Science has been successfully applied. Based on their input, the Commission developed the following Recommendation: “Fund pilot programs to test the effectiveness of applying principles of safety science to improve CPS practice” (CECANF, 2016, p.78).

State Panel: (Ruth Clinard – Child Mortality Review Consultant)

The Minnesota Child Mortality Review Panel is comprised of 30 members and meets 6 times a year. The Child Mortality Review Panel examines up to eight cases at each meeting. The Panel makes recommendations to improve the state and local systems that protect children.

SUID/SDY Subcommittee: (Chairperson – Gloria Mutombo, SUID epidemiologist at Minnesota Department of Health)

The Sudden Unexplained Infant Death and Sudden Death in the Young Subcommittee of the State Panel reviews all sudden unexplained infant deaths and sudden death in the young cases. The subcommittee examines the services provided to the family, and develops recommendations to prevent future deaths.

Local Teams: (Chairperson – county or tribal child protection supervisor)
There are 89 Local Child Mortality Review Teams including two American Indian tribal teams. The local review team conducts a comprehensive review of the facts of the case and makes recommendations to improve local practice and collaboration of the local agencies. Recommendations are also made for changes to state policies and laws.

Purpose

The purpose of the Minnesota Child Mortality Review process is to make recommendations to improve outcomes for all children and families within the child welfare system and prevent future child fatalities and near fatalities.
The Child Mortality Review Panel collaborates with the Minnesota Department of Health to study Sudden Unexplained Infant Deaths and Sudden Deaths in the Young to learn from the cases ways that may help to prevent future deaths.

Data

Standardized data reporting forms are completed for all state reviews. Data from state reviews is entered into the National Center for Child Death Review Case Reporting System.

Prevention Initiatives

The Minnesota Child Mortality Review Panel has partnered with the Minnesota Department of Health to promote infant and child safety messages. Local reviews have resulted in changes to local policy or practice including better collaboration between child welfare partners and local agencies.

Protocols

Minnesota Child Mortality Review has authority to conduct reviews through Minnesota Statutes section 256.01, subdivision 12. The Minnesota Child Fatality/near Fatality On-site Review process is authorized in Minnesota Statutes section 256.01, Subd. 12a. Additional guidelines for mortality reviews are described in the Minnesota Administrative Rule 9560.0232, Subpart 5.

Training

Training aimed at child protection staff responsible for conducting reviews of child fatalities and near fatalities is provided to local agency staff and panel members on a periodic basis (training was provided in July 2016). Technical assistance is provided to counties regarding local reviews whenever needed.

Highly specialized training for conducting the systematic critical incident review process was provided for Department staff and fifteen county and tribal child welfare supervisors in 2017.

Last Updated: March 2018

Program Contact

Ryan Hartneck
Human Services Program Representative II
Continuous Quality Improvement
Child Mortality Review Team
Child Safety & Permanency Division
Minnesota Department of Human Services
444 Lafayette Road North
PO Box 64943
St. Paul, MN 55155-0943
Phone: 651-587-4126
Fax: 651-431-7522
Email: ryan.hartneck@state.mn.us

Craig Lindell
Minnesota Department of Human Services
444 Lafayette Road North
PO Box 64943
St. Paul, MN 55155-0943
Email: Craig.Lindell@state.mn.us

Tools

Minnesota Child Mortality Review Legislation

Mississippi

Program Description

Administration
Legislation establishing a Child Death Review Panel (CDRP) became effective on July 1, 2006 and was revised effective July 1, 2008. The original statute provided for the State Medical Examiner’s Office to have administrative oversight of the CDR panel. During the 2008 regular session of the Legislature, oversight of the Child Death Review Panel moved to the Mississippi State Department of Health (MSDH). The Legislation provided for staff and funding allocations within the MSDH to accomplish the reviews and reporting, and defined the required list of panel participants. 2013 Legislation further refined the required membership of the panel.

Teams
Mississippi has a state level review team comprised of 17 Legislatively mandated voting members.

Reviews
The CDRP reviews data related to infant and child mortality (ages 0-17 years).

Purpose
The Legislatively appointed primary purpose of the panel is to foster the reduction of infant and child mortality and morbidity in Mississippi, and to improve the health status of infants and children.

Data
Data for the reviews are supplied by the Mississippi Vital Statistics and other partners such as the State Medical Examiner’s Office and other agencies with information related to the death i.e. law enforcement etc.

Annual Report
As mandated by the statute, the Child Death Review Panel must submit an annual report to the Chairmen of the House Public Health and Human Services Committee and the Senate Public Health and Welfare Committee on or before December 1. The report shall include the numbers, causes and relevant demographic information on child and infant deaths in Mississippi, and appropriate recommendations to the Legislature on how to most effectively direct state resources to decrease infant and child deaths in Mississippi. The State Department of Health is responsible for printing and distributing the annual report on child and infant deaths in Mississippi.

Prevention Initiatives
The Annual Report cites recommendations for preventive strategies.

Protocols
The review panel is developing and implementing procedures and policies necessary for its operation, including obtaining and protecting confidential records.

Training
County Medical Examiner Investigators have on-going training to appropriately complete the CDC Sudden Unexplained Infant Death Investigation form. Child Death Review staff was trained in the use of the Child Fatality Review National Database software in 2011. This training was provided by the National Center for Child Death Review Program.

Last Updated: March 2026

Program Contact

Claire Mozingo
Director for Child Death Review
Mississippi State Department of Health
Office of Health Data and Research
Bureau of Maternal and Infant Health
570 East Woodrow Wilson Ave
Jackson MS 39216
Phone: 601-576-7482
Email: Claire.Mozingo@msdh.ms.gov

Jessica Jones
Case Abstractor
Phone: 601-576-7809
Email: Jessica.Jones@msdh.ms.gov

Tools

Mississippi Child Death Review Legislation

Missouri

Program Description

Administration
Missouri’s Child Fatality Review Program was established in 1991 by legislation. Its annual budget is $161,700 which is for E&E and is funded through general revenue, plus additional grants. Missouri also has an additional $950,000 for personal services. Funding from year to year is somewhat stable, but is subject to Governor’s reserve and budget cuts. The program is housed out of the Social Services. There are 21 full-time, state-level unit employees and one part-time medical consultant, of which five are directly involved with the Child Fatality Review Program (one each out-posted to the Kansas City and St. Louis metro areas). Missouri’s CDR efforts also include the State Technical Assistance Team, which focuses on child abuse, sexual abuse, exploitation and fatality investigations.

Teams
Missouri has both state and local teams.

State Team:
The Team is comprised of 24 members appointed by the Department Director and meets bi-annually. This panel is responsible for providing oversight and making recommendations to the Department of Social Services and the State Technical Assistance Team. The State Team also has a subcommittee which has reviewed and reported on all 2014 Child Abuse and Neglect deaths.

Local Teams:
Missouri requires each of its 114 counties, and the City of St Louis, to have a multidisciplinary Child Fatality Review Panel. There are 115 teams comprised of seven or more child protection community team members that meet per reviewable death.

Reviews
The Missouri CDR teams review deaths that occur to children under the age of 18. Missouri offers prevention resources, community assistance, and bereavement. These services are provided primarily at the community level.

Purpose
The purpose of the Missouri CDR team is prevention, provision of services, exchange of confidential information for investigative purposes and evaluation for improved practices, policies and procedures by individual agencies. This has always been the focus.

Data
Prior to 2011, standardized data reporting forms were completed for all reviews; in 2011, Missouri converted reporting processes to the National CDR Internet-based case reporting system. The only required paper document is the Child Fatality Review Program Final Report, which is the only open-record document and is required by state legislation and policy. Missouri CDR has access to state vital statistics and child abuse and neglect reporting systems, using this information to link with their data reporting tools. Data is stored in various ways, paper copies are filed, data is entered into an in-house Access database and National CDR Internet-based data reporting system. Data is analyzed through Microsoft Excel and Access software, and department mainframe system queries.

Annual Report
Missouri does produce an annual report. The latest annual report available is for 2023. The report is distributed to a mandatory distribution list which includes government officials and CFRP panel members and is available online at http://www.dss.mo.gov/re/cfrar.htm.

Prevention Initiatives
CDR findings have influenced policy changes. Statewide and local examples of these changes include: a focus in the areas of child fatalities and serious injury prevention, provision of services, crimes and punishment, training and investigation. Prevention activities motivated by CDR findings include training on prevention of child fatalities in the areas of sudden unexpected infant death, unintentional injuries, driver safety programs, fire safety programs, gun safety programs, Safe Crib/Safe Sleep programs and Never Shake A Baby programs. CDR staff actively participates with several multidisciplinary prevention coalitions around the state. Missouri CDR efforts have been evaluated by the University of Missouri Research Program.

Protocols
Missouri CDR has a variety of protocols in place including child death investigation, confidentiality, and the CDR meeting.

Training
Training is provided on a routine basis. Types of training include: individual county-based CDR operational training, CDR program-related and prevention-based presentations, and support for the field-level intervention/investigative community to help realistically convert policy into practice. The trainings are funded with Department funds, the Criminal Justice Act and the Missouri Children’s Trust Fund.

Last Updated: December 2024

Program Contact

Holly Townsend, MET
Missouri Child Fatality Review Program Manager
State Technical Assistance Team
PO Box 208
Jefferson City, MO 65102
Phone: 636-328-2910
Fax: 573-751-1479
Email: Holly.B.Townsend@dss.mo.gov

Website: http://www.dss.mo.gov/stat/mcfrp.htm

Tools

Missouri Child Fatality Review Legislation

Reports

Missouri Annual Reports

Montana

Program Description

Administration
Montana’s Fetal, Infant, Child, and Maternal Mortality Review (FICMMMR) program was established in 1997 through legislation and was amended by the 2013 Legislature to include the review of maternal deaths. FICMMR is housed in the Family and Community Health Bureau (FCHB) at the MT Department of Public Health and Human Services. The State FICMMR Coordinator’s position is funded by the Title V Maternal and Child Health Block Grant (MCHBG) and State General Funds.

Teams
Montana has 31 county mortality review teams, which are defined in state statute. Due to the state’s rural population, 23 other counties utilize a neighboring county’s FICMMR team to help review their county deaths and help generate evidence-based and best practice prevention recommendations. The recipient county is responsible for implementing evidence-based or best practice prevention initiatives in their county. The cooperative agreement serves as an efficient use of review resources for the 54 counties and seven American Indian Reservations.

Reviews

All causes of death of children under 18 years of age and maternal deaths are reviewed by local teams. Some fetal deaths are also reviewed by the county teams, but not all if, after completion of the screening tool, the results do not merit a team review.

Purpose
The purpose of the Montana FICMMR Program is to reduce preventable deaths.

Local review teams are led by a designated county health employee and offer a variety of prevention services: Safe sleep, seat belt and distracted driving education, car seat installation and education for parents, suicide prevention, water & bicycle safety, and distribution of free cribs and child car seats, bicycle helmets, gun locks, etc.

Data
Standardized data reporting forms are completed for all reviews via the web-based National Fatality Review Case Reporting System (NFR-CRS). Montana FICMMR works with the State Office of Vital Records to monitor deaths to assure no deaths are missed. The State FICMMR Coordinator sends a monthly vital statistics report to all FICMMR leaders, so they are continually updated on the deaths of their county residents. In 2013, Montana entered into a Data Use Agreement with the Michigan Public Health Institute allowing the local FICMMR review teams to enter their completed cases in the NFR-CRS. The FICMMR data recorded prior to calendar year 2013 is accessible to the State FICMMR Coordinator and the Maternal and Child Health Epidemiologist.

Prevention Initiatives
FICMMR findings have influenced local changes. Statewide examples of these changes include a requirement that a SIDS diagnosis meet the criteria of autopsy, scene investigation and review of medical history, distribution of handgun safety information during well-child checks, installation of self-locking gates on backyard pool fences, and screening from providers of adolescents for risk of suicide at all routine exams as well as determining if a firearm is present in the home. Prevention activities motivated by FICMMR findings include a request for every hospital to examine infant sleep position policy and model “Safe to Sleep” messages in nurseries, require all licensed day care providers to know CPR, public service announcements on water safety and gun safety; and the successful implementation of the Graduated Drivers Licensing Program.

Protocols
Montana FICMMR resources are available at: http://dphhs.mt.gov/publichealth/cdrp

Training
Trainings, funded through the MCHBG are provided on a quarterly basis. Trainings take the form of webinars, an annual training, on-going individual technical assistance, the Montana FICMMR Guidebook, and newsletters. All new county leaders receive a FICMMR #101 comprehensive training, followed by a hands-on NFR-CRS database training. On-going training and resource distribution includes:: suicide, drowning, SUID deaths motor vehicle accident and distracted driving prevention , Period of Purple Crying as well as team leadership, facilitation, meeting management, recruitment, data quality, and more.

Last Updated: February 2019

Program Contact

Maddie Diederichs
State FICMMR Coordinator
Early Childhood and Family Support Division
1625 11th Avenue
Helena, MT 59620
Phone: (406) 444-3131
Email: Madison.Diederichs@mt.gov

Website: http://dphhs.mt.gov/publichealth/cdrp

Tools

Full FICMMR Act

Nebraska

Program Description

Administration
The Nebraska Child and Maternal Death Review Team (NCMDRT) was established in 1993 by legislation, with authority for maternal deaths added in 2013. Funds from the MCH Block Grant support the program with an annual budget of $70,000. Funding for the program is year-to-year. The program is housed out of the Nebraska Department of Health and Human Services. There are 1.2 FTEs that staff the program and .25 in kind staff. Nebraska is a member of the Midwest Regional CMDR coalition.

Teams
Nebraska has a state level review team.

State Team: (Chairperson – Open)
The team is comprised of 15 members and meets quarterly. The NCDMRT is a retrospective process. The Department of Vital Records is responsible for providing the NCMDRT coordinator with death certificates for all Nebraska residents under the age of 18, with matched birth certificates for infants. The information is screened and organized by cause of death into eight discrete categories, with one overlapping category related to caretaker abuse or neglect. A request is then made to hospitals, county attorneys and other sources for records concerning the deaths of the children. Once all the information is collected, cause-specific workgroups review the deaths. The full CDMRT, as needed, reviews selected cases. These might include complicated medical cases, child abuse and neglect and any others that might benefit from a broader review.

Beginning in January, 2014, maternal death certificates are identified through the pregnancy checkbox on death certificates, and through matching live birth and fetal death certificates to death certificates of women of childbearing age. Resulting information is tabulated and added to the annual CMDRT report. Medical records are requested for maternal deaths that appear to be related to a medical condition, and then reviewed by a separate maternal review workgroup. Case review information will be aggregated on a 5-year basis, and included in that year’s annual report.

Local Teams:
Local infant death review teams, following the FIMR model, are operating in Douglas County (Omaha), and in a five county area in northeast Nebraska.

Reviews
The Nebraska State CMDR team reviews deaths to women within 365 days of a pregnancy, and deaths to children under the age of 18 years old.

Purpose
The purpose of the Nebraska CMDR Program is prevention.

Data
Standardized data reporting forms are completed for all reviews. This is not a required function by state legislation or policy. Nebraska has been participating in the National Center for the Review and Prevention of Child Deaths Case Reporting System.

Nebraska CMDR has access to state vital statistics. The information is extracted from birth and death certificates for purposes of case review. CMDR data are stored in a database and are analyzed by SAS.

Annual Report
Nebraska does produce an electronic annual report based on unreviewed Vital Statistics data from death certificates. A comprehensive report based on CMDRT reviews of deaths is produced approximately every two years. All reports are distributed to the Governor, state legislature, team members and on request; they are also posted to the Nebraska CMDRT website.

Prevention Initiatives
CMDR findings have influenced policy changes. A statewide example of this is graduated drivers licensing. Lots of work is centered on preventing sleep-associated infant deaths.

Protocols
Nebraska CMDR has a variety of protocols in place including CMDR Meeting and confidentiality.

Training
Training is not provided.

Last Updated: February 2019

Program Contact

Celeste Illian
Epidemiology Surveillance Coordinator
Nebraska Health and Human Services System
301 Centennial Mall South, PO Box 95026
Lincoln, NE 68509-5026
Phone: 402-471-0805
Email: Celeste.Illian@nebraska.gov

Website: http://dhhs.ne.gov/publichealth/Pages/lifespanhealth_cdrteam_index.aspx?

Tools

Nebraska Child Death Review Legislation

Nevada

Program Description

Administration
The Nevada CDR program was established in 1993. The program is stand-alone with much of the work conducted by volunteers. In 2003, a law was passed in Nevada that places a one dollar tax on death certificates. The money will be used to fund child fatality review. This fee revenue source fluctuates annually, but provides approximately $117,000 per year.

Teams
Nevada has both state and local teams.

State Team:
The team is comprised of eight members and meets quarterly.

Local Teams:
There are six teams, those in larger urban areas meet monthly, or bimonthly, rural communities meet quarterly when there is a death to review.

Reviews
Nevada CDR Teams review deaths to children age 17 years and younger.

Purpose
The purpose of the Nevada CDR Program is prevention, education and case analysis to determine needed policy, protocol and statute changes.

Data
Standardized data reporting forms are completed for all reviews. This is required by state legislation beginning January 2004. Nevada CDR has access to state vital statistics and uses it for demographic information. CDR data is stored in a private computerized database and is analyzed through statistics.

Annual Report
Nevada does produce an annual report. The annual report features data from six local teams. This report is distributed to all team members, child welfare agency staff, Judicial, Assemblymen and County Commissioners.

Prevention Initiatives
CDR findings have influenced both policy changes and the direction for public awareness campaigns. Policy changes include revised Child Protective Services Intake policies, changes in laws and policies regarding placement of newborns and law enforcement protocols when handling cases of child fatalities and near fatalities. Public awareness campaigns include collaborations with various stakeholders in the community. Some campaigns that the Nevada Child Death Review program has sponsored are:

Emergency mental health response for the crisis stabilization of rural youth: This rural youth suicide prevention program is operated by Desert Rose Counseling Group and provides mobile transitional services with prompt assessment of situational risk. Through a partnership with Integrated Telehealth Solutions, Desert Rose deploys digital tablets with school counselors and/or social workers that facilitate a video interface with mental health counseling services. This program aims to reduce youth suicide by addressing the lack of providers in rural areas of the state as well as lack of youth engagement with mental health treatment.
Suicide prevention for under-represented populations: This suicide prevention program is operated by the Renown Child Health Institute in partnership with the SAFE KIDS Washoe County Coalition and targets under-represented youth populations in Washoe County. This area of the state has a significant Latino population and there is growing concern with suicide rates among this group. Because some teens are under-represented in certain child safety efforts, the program focuses on culturally competent materials and training, including print and social media campaigns. These materials will be shared with community partners and possibly introduced into local schools.
Text4Life: During SFY 2018, the Executive Committee provided continuing funding for both the Text4Life service as well as traditional telephone hotline support for adolescents at risk of suicide. This was first funded in SFY 2015.
safeTALK: The Executive Committee provided funding to the Nevada Coalition for Suicide Prevention (NCSP) to support the provision of Suicide Alertness for Everyone (safeTALK) training to law enforcement agencies and firearm industry members. This program continues the coalition’s efforts to focus on the reduction of access to lethal means, specifically firearms.

Protocols
Nevada CDR has a variety of protocols in place including CDR Meeting and confidentiality requirements.

Training
The training is provided through the child death review fund and is scheduled at the request of the multidisciplinary teams.

Last Updated: October 2023

Program Contact

Dylan Ashley Nall
Social Services Chief II
Nevada Department of Human Services
Division of Child and Family Services
4126 Technology Way
Carson City, NV 89706
Phone: (775) 899-4325
Email: dnall@dcfs.nv.gov

Website: www.dcfs.nv.gov

Tools

Nevada Child Death Review Legislation

New Hampshire

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:

What changes could have prevented the deaths?
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

Program Contact

Amanda Merrill, BSN, RN (She/Her/Hers)
Child and Adolescent Public Health Nurse Consultant
Maternal and Child Health Section
Bureau of Family Health and Nutrition
Division of Public Health Services
NH Department of Health and Human Services
29 Hazen Drive
Concord, NH 03301
Phone: 603-271-8019
Email: Amanda.Merrill@dhhs.nh.gov

Co-Chairs
Angie Raymond Leduc, MBA, CPS
Chair, State Team
Manager, Injury Prevention Center
Dartmouth Health
Email: Angie.M.Raymond.Leduc@hitchcock.org

Jo Porter, MPH
Chair, State Team
Chief Strategy Officer, NH Center for Justice and Equity
Adjunct, UNH
www.nhcje.org
Email: jporter@nhcje.org

Reports

New Hampshire CFR Reports

New Jersey

Program Description

Administration
New Jersey’s Child Fatality and Near Fatality Review Board (CFNFRB) was established in 1997 by legislation. New Jersey’s Child Death Review (CDR) Program is housed in the Department of Children and Families, without dedicated funding. There are four in-kind staff at the state level for the program.

The Department of Health and Senior Services received funding from the Maternal and Child Health Bureau to institute a Mortality/Morbidity Review Project. The goal of this project is to enhance the mortality/morbidity infrastructure in New Jersey by integrating functions of the New Jersey FIMR and Maternal Mortality Review in the Department of Health and Senior Services and the Child Fatality and Near Fatality Review in the Department of Children and Families

Teams
New Jersey has both state and local teams. The state level team is mandated by statute and the local teams are permitted. New Jersey also has a Sudden Unexplained Infant Death sub-committee and a suicide sub-committee.

State Team: (Chairperson – Dr. Kathryn McCans)
The CFNFRB is composed of 13 ex-officio members with expertise in the treatment and prevention of child abuse and neglect. The board also has public members. The CFNFRB meets monthly to review the deaths of active child protection cases or deaths in which the child was involved with child protective services within the last 12 months. By law, the board can determine which fatalities receive full review. The CFNFRB also serves as a Citizen’s Review Panel.

Local Teams:
The CFNFRB has established three Regional Community-Based Review Teams with the support of the Regional Child Protection Centers that meet monthly. They look at all categories of child death with the exception of active child protection cases. By law, these teams must include at a minimum, a person experienced in prosecution, a person experienced in local law enforcement investigation, a medical examiner, a public health advocate, a physician, preferably a pediatrician and a casework supervisor from a field office of the Division of Child Protection and Permanency.

Reviews
Deaths of children under the age of 18 years old are reviewable. The board reviews all deaths involving children who were involved with child protective services at the time of their death or near fatal incident and those children who were involved with child protective services within 12 months prior to their death or near fatal incident with the exception of SUID/SIDS/Undetermined cases of children under one year old. New Jersey uses the following definition to determine reviewable near fatalities: “A serious or critical condition, as certified by a physician, in which a child suffered a permanent mental or physical impairment, a life threatening injury or a condition that creates a probability of death within the foreseeable future”.

The local teams review all other fatalities involving the following causes: undetermined, substance use, malnutrition, dehydration, medical neglect, failure to thrive, sexual abuse, head trauma, fractures, blunt force trauma, and burns without obvious innocent reason, suffocation, asphyxia and drowning. The SUID subcommittee reviews SUIDS/SIDS/Undetermined cases of children under 12 months and the suicide subcommittee reviews all child suicides.

Purpose
The purpose of the New Jersey CDR Program is to identify the relationship of childhood fatalities to government support systems and methods of prevention.

Data
Standardized data reporting forms are completed for all reviews as required by statute. Data are collected on the reviews and compiled in a database managed by the Office of Performance Management and Accountability. Additionally, the New Jersey Mortality/Morbidity Review Project is working to implement a comprehensive mortality/morbidity review data information system.

Annual Report
New Jersey does produce an annual report. This report is posted on the Department of Children and Families web site.

Protocols

The CFNFRB has meeting, confidentiality and child/infant death investigation protocols.

Last Updated: January 2020

Program Contact

Tamika Young
Manager – Fatality & Critical Incident Review Units
Department of Children and Families
Office of Quality
50 E. State St. 2nd floor
P.O. Box 717
Trenton, NJ 08625
Phone: 609-888-7665
Email: Tamika.Young@dcf.nj.gov

Website: http://www.nj.gov/dcf/providers/boards/fatality/

Tools

New Jersey Child Fatality Review Legislation

Reports

Fatality Review Reports

North Carolina

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:

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:

Undetermined causes
Unintentional injury
Violence
Motor vehicle incidents
Sudden unexpected infant death
Suicide
Deaths not expected in the next six months
Deaths related to child maltreatment or child deaths involving a child or child’s family who was reported or known to child protective services*
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.

Program Contacts

State Office of Child Fatality Prevention

Website: https://www.dph.ncdhhs.gov/programs/office-child-fatality-prevention

Kerry Young, Director
1928 Mail Service Center
Raleigh, NC 27599-1928
Email: Kerry.Young@.dhhs.nc.gov

Donice Mann, Database Specialist
1928 Mail Service Center
Raleigh, NC 27599-1928
Email: Donice.Mann@.dhhs.nc.gov

North Carolina Child Fatality Task Force

Website: https://sites.ncleg.gov/nccftf/

Kella Hatcher, Executive Director
2001 Mail Service Center
Raleigh, NC 27699
Email: kella.hatcher@dhhs.nc.gov

New Mexico

Program Description

Administration
The New Mexico Child Fatality Review was (NM-CFR) established in 1998, with the implementation of Title 7 of the New Mexico Administrative Code (NMAC) Chapter 4- Disease Control, Part 5, Maternal, Fetal, Infant and Child Death Review (NMAC 7.4.5). The teams are coordinated and facilitated by the New Mexico Department of Health.

Teams
New Mexico’s CFR team consists of four state-level review panels. These include Child Abuse and Neglect; Suicide; Sudden Unexplained Infant Death (SUID); and Unintentional Deaths. The membership of these panels include individuals representing various professional disciplines, topic experts, agencies, and advocacy groups.

State Team:
New Mexico’s CFR team consists of five state-level review panels. These include Child Abuse and Neglect, Suicide, Sudden Unexplained Infant Death (SUID), Unintentional Deaths and Youth Violence. The membership of these panels includes individuals representing various professional disciplines, topic experts, agencies, and advocacy groups. Each panel meets monthly or quarterly to review cases, identify risk and protective factors, system failures or gaps, and determine prevention recommendations. This information is shared with policymakers, providers, communities, and the public in the annual report.

State Support Staff:
The NM-CFR state team consists of the NM-CFR Coordinator as well as colleagues from the Office of Injury and Violence Prevention.

Reviews
The NM-CFR reviews all non-natural child fatalities in New Mexico (NM). Deaths occurring on tribal land or reservations are not reviewed by the state CFR. Deaths are identified through the Bureau of Vital Records and Health Statistics and the NM Office of the Medical Investigator. This information is sent to the NM-CFR Coordinator, who collects case information and notifies the appropriate panel that the case is ready for review.

Purpose
The purpose of the NM-CFR is to gather and analyze information related to childhood fatalities to identify gaps in care and strategies to inform future prevention efforts. An important component of this is improving coordination among agencies that engage with families.

Data
NM-CFR uses the National Fatality Review Case Reporting System (NFR-CRS), the web-based database developed by the National Center for Fatality Review and Prevention.

Annual Report
Per statute, NM produces an annual report.

Prevention Initiatives
NM-CFR findings have influenced policy changes and prevention initiatives.

Protocols
New Mexico has established CFR meeting protocols in place, which include terms of confidentiality.

Training
Training is ongoing for established panel members. New panel members receive training resources and mentoring. The Office of the Medical Investigator conducts training in death scene investigation.

Last Updated: March 2024

Program Contact

Lisa Rohleder, MA
Child Fatality Review Coordinator
Center for Health Protection
Public Health Division
New Mexico Department of Health
Phone: 505-490-7333
Email: lisa.rohleder2@doh.nm.gov

Email: NMCFR@doh.nm.gov

Tools

New Mexico Child Fatality Review Regulations

Reports

New York

Program Description

Administration

In 1999, legislation was enacted authorizing the creation of local or regional child fatality review teams in New York. The New York State Office of Children and Family Services (OCFS) is the state agency responsible for various administrative functions relating to this program.

New York State Social Services Law Section 422-b

Chapter 136 of the Laws of 1999

Chapter Law 485 of the Laws of 2006
New York State Social Service Law allows a child fatality review team (CFRT) to be established at a local or regional level, with the approval of OCFS. The purpose of the CFRT is to review the death of any child whose care and custody or custody and guardianship has been transferred to an authorized agency, any child for whom child protective services has an open case, any child for whom the local department of social services has an open preventive services case, and in the case of a report made to the New York Statewide Central Register of Child Abuse and Maltreatment involving the death of any child. A CFRT may also investigate any unexplained or unexpected death of any child under the age of eighteen.

A CFRT must include, but is not limited to, representatives from the local Child Protective Service, OCFS, county department of health, or, should the locality not have a county department of health, the local health commissioner or his or her designee or the local public health director or his or her designee, Office of the Medical Examiner, or, should the locality not have a medical examiner, Office of the Coroner, Office of the District Attorney, Office of the County Attorney, local and state law enforcement, Emergency Medical Services and a pediatrician or comparable medical professional, preferably with expertise in the area of child abuse and maltreatment or forensic pediatrics. A CFRT may also include representatives from local departments of social services, mental health agencies, domestic violence agencies substance abuse programs, hospitals, local schools and the Family Court.

A CFRT approved by OCFS has access to all records, except those protected by statutory privilege, within twenty-one days of receipt of request. Such access includes access to pending, indicated and unfounded reports of child abuse or maltreatment. Members of a CFRT, persons attending a meeting of a local or regional fatality review team, and persons who present information to a local or regional fatality review team have immunity from civil and criminal liability for all reasonable and good faith actions taken pursuant to this law, and may not be questioned in any civil or criminal proceeding regarding any opinions formed as a result of a meeting of the CFRT. A CRFT may exercise the same authority as OCFS with regard to the preparation of a child fatality report.

All meetings conducted and all reports and records made and maintained, and books and papers obtained, by a CFRT are confidential and not open to the general public except by court order and except for an annual report or a fatality report, if the team chooses to complete such a report. A CFRT may not redisclose confidential information, except where otherwise authorized by statute.

Teams
New York has local and regional review teams. There is no state level advisory committee.

Local Teams:
New York has local teams. The state level Regional Offices of OCFS must be one of the members of each CFRT. The City of New York is developing a review process.

Reviews
Teams review cases involving children age 17 and younger. Deaths are reviewed due to SIDS, homicides, suicides and abuse/neglect. Additionally, cases that had involvement with OCFS and deaths of children in foster care are reviewed.

Purpose
The purpose of the New York child fatality review process is to prevent future deaths, to assist in the investigative process and improve the social services system.

Data
Data collected for the review process includes information from databases on child maltreatment and foster care children.

Annual Report
An annual report is submitted to the Governor and legislature. It includes a section on recommendations directed at the state’s child advocacy system, not exclusively child fatality review.

Prevention Initiatives
In 2016, OCFS began the Sleep Environment Survey. The 4-month long survey is taken online or over the phone by new parents who delivered children in four pilot hospitals in NYS. The data is providing valuable information on Safe Sleep practices in hospitals.

To increase the use of safe sleep practices, OCFS developed a Safe Sleep kit. The kit is being used as part of the Sleep Environment Survey and is provided to community organizations upon request to increase Safe Sleep practice and awareness. The kit includes:

A tote bag with the “Follow the ABCs of Safe Sleep” printed on the bag
A “Follow the ABCs of Safe Sleep” brochure, magnet, and window cling
The “Sleep Baby, Safe and Snug” book written by Dr. John Hutton
A DVD developed by OCFS. The video is can be viewed at http://ocfs.ny.gov/main/cps/safe_sleep_video.asp or http://www.youtube.com/TheNYSOCFS.

Protocols
In 2012, OCFS revised their templates for standard protocols and guidelines for the approval and certification of the 18 funded CFRTs in New York State.

Training
An annual event for CFRT Coordinators was introduced in planned 2014.

Last Updated: January 2017

Program Contact

Ed Guidry
Director of the Bureau of Child Fatality Review and Prevention
Office of Children and Family Services
52 Washington St.
Room 230 North
Rensselaer, NY 12144

Phone: (518) 474-4783
Email: Ed.Guidry@ocfs.ny.gov

Website: http://www.ocfs.state.ny.us

Tools

North Dakota

Program Description

Administration
The North Dakota Child Fatality Review Panel was established in 1995 by statute. Case reviews began in 1996. The program is housed out of the Department of Human Services. There is no annual budget and funding for the program is in kind. One staff person on the state level spends 20% of her time working on the CFR project.

Teams
North Dakota has a state level review team.

State Team: (Presiding Officer – Marlys Baker, Administrator, Child Protection Services, North Dakota Department of Human Services)
The panel has 14 team members who meet quarterly.

Reviews
All child deaths are reviewed. However, all deaths are not reviewed with the same level of intensity. An in-depth comprehensive review is done on all sudden, unexplained and unexpected deaths. The panel also reviews all child abuse and neglect near deaths. The panel reviews deaths of children who are less than 18-years-old.

Purpose
The purpose of the North Dakota Child Fatality Review Panel is to identify circumstances that contribute to children’s deaths and to recommend changes in policy, practice and law to prevent children’s deaths.

Data
Data is collected on all reviews. This is not required by legislation or policy. The CFR data is stored in Microsoft Access and is analyzed by the research unit within the Department of Human Services.

Annual Report
The CFR Panel does produce an annual report. The report is distributed to panel members, state attorneys, coroners, law enforcement and others by request. The report is also published on the North Dakota Department of Health website.

Prevention Initiatives
The North Dakota Child Fatality Review Panel recommends changes in policy, practices and law to prevent child deaths.

Protocols
North Dakota has state law and program policy in place which directs the function of the Child Fatality Review Panel.

Training
On-going training is not offered. However, an orientation to the review process is provided to new team members.

Last Updated: January 2018

Program Contact

Jenn Grabar
Child Protection Services Assistant Program Administrator
ND DHS – Children and Family Division
600 East Blvd. Avenue Dept. 325
Bismarck, ND 58505
Phone: 701-328-1863
Fax: 701-328-3538
Email: jjgrabar@nd.gov

Website: http://www.nd.gov/dhs/info/pubs/Family.html

Tools

North Dakota Child Fatality Review Legislation

Idaho

Program Description

Administration
Recognizing the need to better understand why children die, in July 2000, Governor Bob Taft signed into law the bill establishing the Child Fatality Review (CFR) program for Ohio. Local boards in each county are mandated to review all deaths from all causes to children under 18 years of age. The mission is to reduce the incidence of preventable deaths in Ohio. The Ohio Department of Health (ODH) and the Ohio Children’s Trust Fund are responsible for administration and program support of CFR. A full-time state coordinator is employed by ODH.

The annual budget for the Ohio CFR program is about $150,000. This includes the salaries of all staff involved, training and producing an annual state report. There are 1.25 FTE’s at the state level. Funding for the program comes from the MCH Block Grant.

Teams
Ohio has 88 local boards and a state advisory committee.

State Advisory Committee:
The State CFR Advisory Committee was established in April 2002 to assist in moving the process ahead in Ohio. The purpose of this committee is to review Ohio’s child mortality data and CFR data to identify trends in child deaths; to provide expertise and consultation in analyzing and understanding the causes, trends and system responses to child fatalities in Ohio; to make recommendations in law, policy and practice to prevent child deaths in Ohio; to support CFR and recommend improvements in protocols and procedures; and to review and provide input for the annual report. The committee membership represents diverse professions, state agencies and external partners.

Local Teams:
All reviews are conducted by 88 county boards that meet at least once per year.

Reviews
Ohio’s CFR boards review deaths from all causes to children younger than 18 years of age. By law, boards may review child deaths retrospectively (deaths that occurred one year in the past) or concurrently (deaths that occurred in the current year). Due to increasing demand for the most current data, beginning in 2014, all boards began reviewing deaths in the year in which the death occurred.

Purpose
Ohio established a CFR Program to better understand how and why children die and to take action to prevent other child deaths. The purpose of the local Child Fatality Review boards is to reduce the incidence of preventable child deaths.

Data
Ohio uses the national Child Death Review Case Reporting System. Each local board enters case data into a Web-based system which allows ODH to access data for aggregate state reports.

Annual Report
Ohio produces an annual state report, which is distributed as required by law to elected state officials and to additional interested parties. The report includes review findings for all causes of death as well as recommendations and initiatives for prevention of further deaths. The report is available on the ODH Web site. Many of the local teams produce county level reports.

Prevention Initiatives
More than half of the 88 counties reported over 100 examples of successful implementation of CFR recommendations. Details about initiatives can be found in the state annual report.

Sleep-related Deaths: The largest number of initiatives reported deal with reducing the risk of sudden infant death syndrome (SIDS) and other sleep-related deaths. A variety of programs target minority families, grandparents, caregivers, health professionals and the whole community with risk reduction messages that include Back to Sleep, and the risks of inappropriate bedding and bedsharing. Many of these initiatives are on-going, being incorporated into existing programs such as prenatal clinics, Help Me Grow (HMG) and Special Supplemental Food Program for Women, Infants and Children (WIC). Efforts to reach the whole community include the use of billboards, displays at fairs and festivals and distribution of educational materials at popular sites for families such as zoos, playgrounds and family restaurants. Agency policies are adapted to institutionalize practices that reinforce safe sleep behaviors. Recent legislation spurred by CFR findings requires hospitals to screen for the availability of a safe sleep space before discharging a newborn infant, and to provide a safe crib if one is needed.
Child Abuse and Neglect: The CFR process can identify opportunities for improvement in programs and policies to prevent child abuse and neglect. Responsibility for prevention activities is shared among all the member agencies. The Ohio Children’s Trust Fund (OCTF) helps fund community based primary and secondary child abuse prevention programs using evidence based curricula.
Suicide: The need for youth suicide prevention is also being addressed as a result of the CFR process. In many counties, CFR findings are shared with county suicide prevention coalitions and task forces to focus on awareness of suicide and develop strategies to reduce the factors that increase the risk of suicide, identify youth at risk and increase the availability of mental health services.
Vehicular Injuries: Vehicular crashes continue to be a leading cause of injury and death to children. Many local CFR boards were involved in efforts to pass Ohio’s Distracted Driving law which took effect in August 2012. Boards are active in educating families about the new law, in addition to Ohio’s Booster Seat law and Graduated Driver License law. In addition to continued efforts in most counties to improve teen driver education and infant car seat programs, local CFR boards are addressing specific issues regarding vehicular deaths in their community.
Infant Deaths: Although only 12 percent of infant deaths were deemed preventable, CFR boards recognize the detrimental effects of unhealthy lifestyles and poor prenatal care on the lives of infants. In response to needs identified through the reviews of infant deaths, many counties have launched collaborative efforts to reduce infant mortality. Typical partners include HMG, WIC, Child and Family Health Services projects, local physicians, schools and other health and social service providers.
Substance Abuse: The misuse and abuse of prescription drugs and other substances harms youth and children, who suffer intentional or accidental overdose and prenatal exposure as well as inadequate care and supervision when adults use. Local CFR boards have joined with other community agencies to combat this epidemic and protect children.
General Health and Safety: Countywide collaborations and partnerships produced many programs to increase the general health and safety of children.
Systems Improvements: One of the goals set by Ohio law for CFR is to promote cooperation, collaboration and communication among all groups that serve families and children. The CFR process continues to have a positive impact on participating agencies. Many boards report an increase in cooperation and understanding between participating agencies and some have developed written policies to facilitate communication. The review process stimulates discussion about existing services in communities, identifying gaps in services, access to service barriers, the need to maximize use of existing services and opportunities for increased collaboration.

Protocols
Ohio has a CFR meeting protocol in place.

Training
Training for local review teams is organized by the Ohio Department of Health in partnership with the Ohio Children’s Trust Fund and experienced CFR teams.

Last Updated: February 2023

Program Contact

Aubrie M. Sanchez, MS, MPH, CCRP
Ohio Department of Health
Bureau of Maternal, Child and Family Health
246 N. High St., 4th Floor
Columbus OH 43215
Phone: (614) 903-0187
Email: aubrie.sanchez@odh.ohio.gov

Website: https://odh.ohio.gov/know-our-programs/child-fatality-review/Child-Fatality-Review

Tools

Ohio Child Fatality Review Legislation

Reports

Ohio Annual Reports

Oklahoma

Program Description

Administration
Oklahoma’s Child Death Review Board was established in 1991 and is a program of the Oklahoma Commission on Children and Youth. Funding for the program is year-to-year. There are currently four full-time employees and two interns.

Teams
Oklahoma has both a state and regional teams. Currently, there are four regional teams reviewing cases. Teams conduct retrospective/periodic case reviews for their geographic area.

State Team: (Chairperson – Dr. Scott Melson, Pediatrician representing AAP) The team is comprised of 24 members.

Eastern Regional Team: (Chairperson – Kelly Mounce, Licensed Mental Health Professional) The team is comprised of 6 members and meets quarterly.

Southwestern Regional Review Team: (Chairperson – Cindy Nocton, Post-Adjudication Review Board) The team is comprised of 6 members and meets quarterly.

Southeastern Regional Review Team: (Chairperson – Jerry Frye, Social Services, Retired) The team is comprised of 7 members and meets quarterly.

Tulsa Regional Review Team: (Chairperson – Rose Turner, LCSW, Vice President of Clinical Programs and Counseling, Domestic Violence Intervention Services, Inc.) The team is comprised of 6 members and meets bi-monthly.

Reviews
Oklahoma CDR teams review unattended deaths of children under the age of 18 years old. Serious injuries/near fatalities are also reviewed.

Purpose
The Oklahoma CDR is statutorily required to:

Establish and maintain statistical information related to the deaths and near deaths of children including, but not limited to, demographic and medical diagnostic information;
Review the policies, practices, and procedures of the child protection system and make specific recommendations to the entities comprising the child protection system for actions necessary for the improvement of the system;
Review the extent to which the state child protection system is coordinated with foster care and adoption programs and evaluated whether the state is efficiently discharging its child protection responsibilities under the federal Child Abuse Prevention and Treatment Act state plan;
As necessary and appropriate, for the protection of the siblings of a child who dies and whose siblings are deemed to be living in a dangerous environment, refer specific cases to the Department of Human Services or the appropriate district attorney for further investigation;
Report, if recommended by a majority vote of the Board, to the President Pro Tempore of the Senate and the Speaker of the House of Representatives any gross neglect of duty by any state officer of state employee, or any problem within the child protective services system discovered by the Board while performing its duties;
Recommend, when appropriate, amendment of the cause or manner of death listed on the death certificate.

Data
Standardized data reporting forms are completed for all reviews are entered onto a web based database. CDR data is stored electronically and is analyzed statistically.

Annual Report
Oklahoma does produce an annual report and is submitted to the Oklahoma Commission on Children and Youth and any additional interested parties.

Prevention Initiatives
Although the Oklahoma Child Death Review Board is not statutorily required to create and/or participate in prevention initiatives, CDR findings have influenced policy and procedural changes. Statewide examples include automatic toxicology screens for all unexplained deaths of children, autopsies are now required in all deaths before the manner of death can be listed as SIDS and a death scene investigation card has been created for all first responders in the state. Prevention activities include the passage of legislation for a graduated driver’s license program and improvements to child passenger restraint laws. The Oklahoma CDRB is also a partner in the statewide infant mortality initiative Preparing for a Lifetime: It’s Everyone’s Responsibility (PFL), with CDRB staff involved in statewide efforts to reduce of abusive head trauma.

Protocols
Oklahoma CDR has a variety of protocols in place including CDR meeting, child death investigation (death scene investigation cards and promotion of SUIDI protocols) and confidentiality.

Training
Training for new board members is conducted by staff and senior board members.

Last Updated: April 2026

Program Contact

Elizabeth Kaup or Joseph McGrath
Oklahoma Child Death Review Board
2915 N. Classen Blvd., Suite 300
Oklahoma City, OK 73106

Phone: (Lizz) 405-606-4900 or (Joseph) 405-421-6472
Email:Elizabeth.kaup@occy.ok.gov or Joseph.mcgrath@occy.ok.gov

Website: http://www.ok.gov/occy/Programs/Child_Death_Review_Board/

Tools

Oklahoma Child Death Review Legislation

Oregon

Program Description

Administration
The Oregon State Child Fatality Review Team was established in 1989. In 1991, county level child fatality review processes were established. In order to provide technical assistance to these local teams, the legislature established the State Technical Assistance Team (STAT) in 1995 which was housed in the Injury and Violence Prevention Program in Public Health. Funding for this team was eliminated in 2000. Funding for counties goes to District Attorney Offices who operate multidisciplinary teams (MDT) for the investigation of child abuse. The statute that established the MDT requires these teams to set up a CFR process. Funding for the MDT activities also covers the CFR work but it is not funding directed to CFR activities. The amount of funding to the local communities varies. CFR activities are an add on to the MDT statute. There are team members who conduct CFR activities as part of their job responsibilities.

Teams
Oregon has both state and local CFR teams.

State Team Chairperson(s): Michele Stauffenberg, MD, State Medical Examiner and Deborah Carnaghi, LCSW, State Child Protective Service Program Manager
The Oregon State Child Fatality Review Team has 20 members that meet twice a year. The purpose of their meetings is to make recommendations and take actions involving statewide child fatality issues.

Local Teams:
District attorney offices chair local teams in Oregon. There are 36 teams in Oregon, each consisting of approximately ten members. Teams are made up of representatives from at least five key agencies: law enforcement, the district attorney, child protective services, public health and the medical examiner. In many counties, representatives from Emergency Medical Services, Victims Assistance Programs, Juvenile Justice, Fire Department, Schools and local health care providers participate in the process. Teams conduct retrospective/periodic reviews.

Reviews
Teams review unexpected deaths including homicides, suicides, accidents, unexpected natural deaths and deaths due to an undetermined manner to children less than age 18.

Purpose
The purpose of CFR in Oregon is investigation, prevention, quality assurance, data collection and to provide services. This is the focus in statute. There is a shift on the state level to primarily a prevention focus. The local teams also work on prevention.

Data
Oregon began participating in the National Child Death Review Data System in 2013. Cases beginning 1/1/14 were entered into this system. Local teams can contact the IVPP staff, their local health department or the Center for Health Statistics to request copies of death certificates. Staff also use vital records to create lists of cases that should be reviewed and provide them to the local District Attorney’s office when requested to assure that cases are identified and reviewed.

Annual Report
Annual reports on child death due to violence, maltreatment, suicide and injury are produced as part of an annual injury report that is produced by the injury epidemiologist. The report includes recommendations for prevention and policy and is linked to the five year state prevention plan.

Prevention Initiatives
CFR findings have influenced policy changes on the state level. There was a change in the child abuse statutes to eliminate the religious beliefs exemptions for homicide cases. Statutes to prohibit children from riding in the back of pickup trucks, requiring helmets when skating, riding scooters and skate boards, booster seat requirements and the prohibition of the resale of older cribs that are dangerous in second hand stores have been passed. Statute was passed to outlaw toy lighters and mandate fire safe cigarettes. Additionally, prevention information is provided to all new parents through the state newborn handbook including information on safe sleep environment, home safety, and child passenger safety. CFR findings have also implemented prevention initiatives at the local level. Examples include: The state developed a suicide prevention plan that is being implemented by local groups. Oregon coastal communities implemented a prevention program to reduce the number of deaths due to logs rolling over kids playing on driftwood. Clackamas County established a lifeguard at two public swimming beaches on the Sandy River. Safe Kids coalition continue to partner with local teams to distribute helmets and safety seats to low income families with children. A window falls prevention alliance has developed a communications strategy to prevent window fall injuries among children.

Protocols
Oregon CFR has meeting, confidentiality and child/infant death investigation protocols in place.

Training
Training on the CFR process is presented by DOJ staff for Victim’s Assistance staff working for local DAs. Training on using the national data entry system was provided to local teams in 2013.

Last Updated: February 2019

Program Contact

Robyn Ellis
CDR Coordinator
Oregon Health Authority
800 NE Oregon Street, Suite 730
Portland, OR 97232
Phone: 971-673-1098
Fax: 971-673-0990
Email: Robyn.E.Ellis@dhsoha.state.or.us

Tools

Oregon Child Fatality Review Legislation

Pennsylvania

Program Description

Administration
Pennsylvania’s CDR Program was established in November 1994. It began as a pilot study without legislation. In October 2008, Pennsylvania passed legislation mandating that counties participate in child death reviews. The program has an annual budget of approximately $160,000 and is funded by the Department of Health. The program is housed within the Pennsylvania Department of Health, Bureau of Family Health. There are 1.75 employees at the state level that staff the program.

Teams
Pennsylvania has both a state team and local teams.

State Team:
The team is comprised of selected members and representation from a variety of disciplines.

Local Teams:
Pennsylvania has 64 local review teams. All 67 counties in the state participate on state and/or local teams. Teams do not receive any funding from the state.

Reviews
Pennsylvania CDR teams review all deaths of children from birth through their 21st year. There are approximately 2,000 deaths each year. At this time team are reviewing approximately 75% of all child deaths.

Purpose
Pennsylvania Child Death Review has a focus on prevention. This activity is accomplished by identifying factors which cause a risk for injury and death, including modifiable risk factors; making recommendations regarding the improvement of health and safety policies in the Commonwealth and coordinating services and investigations. Local teams make recommendations relating to the procedures and other actions to local agencies to reduce injury and death of children.

Data
The Pennsylvania Public Health Child Death Review Act requires that local teams utilize the National Fatality Review Case Reporting System to report its findings in accordance with the established protocol.

Annual Report
Pennsylvania produces an annual report that is submitted to the Governor and the General Assembly by the end of September of each year. The report includes summary of reports received by local child death review teams and recommendations relating to the reduction of risk of child injury and death. Annual reports are posted on the PA Department Health website.

Prevention Initiatives
Examples of how CDR findings have motivated prevention activities include local projects that are developed and implemented by local teams and their community prevention partners.

Suicide Prevention: PA CDRT will continued provide support to Pennsylvania Youth Suicide Prevention Initiative.

Safe Sleep: Recommendations continue to encourage CDR teams to collaborate with key stakeholders within their communities.

Sudden Unexpected Infant Death (SUID) Case Registry: This project focuses on infants deaths related to the sleep environment and focuses on efforts to prevent future deaths.

Protocols
Pennsylvania CDR has confidentiality protocols in place.

Training
Training is provided annually on an as-needed basis to all CDR teams. All CDR members are invited to attend an annual meeting and regional meetings each year.

Last Updated: February 2019

Program Contact

Mike Krausse
Public Health Program Administrator
Department of Health; Bureau of Family Health
Phone: 717-547-3381
Email: RA-DHPACDR@pa.gov

Angelo Santore
Pennsylvania Department of Health
Health and Welfare Building, 7th Floor East Wing
625 Forster St.
Harrisburg, PA 17120
Phone: 717-547-3382
Fax: 717-772-0323
Email: RA-DHPACDR@pa.gov

Website: Pennsylvania Child Death Review

Annual Reports

Rhode Island

Program Description

Administration
The Rhode Island Child Death Review Team was established in 1997 and is housed out of the RI Department of Health, Office of the State Medical Examiners. The program has a budget of funded by Rhode Island Department of Health. The funding supports 0.4 FTEs and includes time and effort for a coordinator and data manager. Rhode Island is also a member of the Northeast Regional Coalition of State CDR Programs.

Teams
Rhode Island has one state team.

State Team:
The team is comprised of 22 members and meets 8-10 times a year.

Reviews
Rhode Island’s State CDR team reviews deaths to children through 17 years of age. Rhode Island reviews deaths due to SUID, injuries, homicides, suicides, abuse/neglect and deaths of natural causes that are potentially preventable such as those due to asthma. Reviews are conducted retrospectively. The CDRT team reviews approximately 30 CDRT eligible deaths each year. The state also has domestic violence and maternal mortality reviews.

Purpose
The purpose of the Rhode Island CDR Program is to bring together a multi-disciplinary team from across the state to share information and ideas through the review of individual child deaths and child death data. The group works together to analyze and make recommendations to prevent child deaths in the state.

Data
Rhode Island CDR has access to state vital statistics which are used in conjunction with Medical Examiner data. Rhode Island enters all known cases of child deaths occurring in Rhode Island into the National Center for Child Death Review web-based reporting system.

Annual Report
Rhode Island has produced annual reports which are submitted to the Director of the RI Department of Health. Special topics reports have been prepared for distribution to legislators, media, policy makers and professional groups. Summary data reports are being developed every three years, the current report includes 2015-2017.

Prevention Initiatives
CDR findings have influenced policy changes at the agency level. CDC findings are utilized in state presentations to the Children’s Cabinet, statewide child safety conferences and state and local application for additional funding to sustain child death prevention efforts.

Protocols
Rhode Island has CDR Meeting, confidentiality, preventability assessment and child death investigation protocols in place.

Training
Rhode Island provides training on a quarterly basis during the open portion of the CDRT meetings.

Last Updated: January 2019

Program Contact

Shannon Young
Coordinator, Child Death Review Team
Rhode Island Department of Health
48 Orms Street
Providence, RI 02904
Phone: 401-222-5504
Email: Shannon.young@health.ri.gov

South Carolina

Program Description

Administration
The State Child Fatality Advisory Committee (SCFAC) was enacted in 1993 and is mandated by S.C. Code 63-11-1950 to identify patterns in child fatalities that will guide efforts by agencies, communities and individuals to decrease the number of preventable child deaths.

As defined by S.C. Code 63-11-1910 and S.C. Code 17-5-540 a “child” means a person less than eighteen years of age. Any child death under the age of 18 is investigated when the death is unexpected and unexplained including, but not limited to, possible sudden infant death syndrome (SIDS), as a result of violence, when unattended by a physician or when occurring in any unusual or suspicious manner.

The intent of the child fatality review process is to decrease the incidence of preventable child deaths and make the public more aware of intentional and unintentional child deaths.

Teams
State Team:

Amanda Whittle, J.D., Chair-person
State Child Fatality Advisory Committee
Email: Amanda.Whittle@childadvocate.sc.gov

Mary-Fran Crosswell, M.D., Co-Chair person
State Child Fatality Advisory Committee
Email: Mary-Fran.Crosswell@prismahealth.org

The State Child Fatality Advisory Committee (SCFAC) is staffed by the State Law Enforcement Division’s (SLED’s), Special Victim’s Unit – Investigative Program. The SCFAC membership follows child fatality review (CFR) meeting, confidentiality and child/infant death investigation protocols, with standardized data reporting forms completed for all reviews. The SCFAC holds regular meetings during the months of February, April, June, August, October and December.

The SCFAC current membership consists of representatives from:

Department of Social Services
Department of Health and Environmental Control
Department of Education
SC Criminal Justice Academy
Department of Mental Health
Department of Alcohol and Other Drug Abuse Services
Department of Juvenile Justice
Department of Disabilities and Special Needs
SC Attorney General Office
SC Chapter of the Academy of Pediatrics
SC Children’s Trust Fund
Ninth Circuit Solicitor
County Coroner or Medical Examiner
Forensic Pathologist
State Law Enforcement Division
SC Senate
SC House of Representatives
SC Network of Children’s Advocacy Centers (Public)
SC Crime Victims’ Council (Public)

Efforts by the SCFAC to obtain a better understanding of the causes of child death through a review of preventable child deaths help implement changes within the agencies represented, and provide recommendations to the Governor and the General Assembly on statutory, policy and practice changes, which will prevent future child deaths.

Local Teams
South Carolina consists of 46-county areas with each having an elected Coroner. Each Coroner Office independently reviews each child fatality in coordination with local law enforcement partner organizations, with many engaging voluntary Children’s Health and Safety or Child Death Review Teams.

The SCFAC’s goal is to have a standing Child Fatality Team (at a minimum) functioning in each of the state’s forty six (46) county areas, with each local team composed of a standard group of members and using a standardized child fatality review tool; the National Center’s Case Reporting System. The gold standard would be for each county child fatality team to be comprised of a representative from the following: Coroner’s Office, Local Law Enforcement, SLED SVU Agent, Solicitor’s Office, Social Services, and Medical (child abuse pediatrician)

Reviews

The South Carolina SCFAC (state CDR Team) reviews preventable deaths of children under the age of 18 years old. The goal of the SCFAC is to review 252 child death cases annually, with 42 case reviews conducted at each bi-monthly meeting. Investigative reports, including autopsies, death certificates, law enforcement investigation reports, child welfare involvement, coroner reports, and other pertinent case information from state agencies (see listed SCFAC current membership representatives in Teams section above) are reviewed for each selected child death case during the review meeting.

Purpose

The purpose of the SCFAC (state CDR team) is to decrease the incidences of preventable child deaths by:
(1) developing an understanding of the causes and incidences of child deaths;
(2) developing plans for and implementing changes within the agencies represented on the committee which will prevent child deaths; and
(3) advising the Governor and the General Assembly on statutory, policy, and practice changes which will prevent child deaths.

Data

To achieve its purpose, the SCFAC shall undertake annual statistical studies of the incidences and causes of child fatalities in this State. The studies shall include an analysis of community and public and private agency involvement with the decedents and their families before and subsequent to the deaths.

The SCFAC (state CDR team) utilizes the National Center’s Case Reporting System for data collection. It is the goal of SCFAC that each of the 46 county CDR teams will utilize the National Center’s Case Reporting System on all deaths that undergo a local team review.

In addition, data is entered into an Access database by the state CDR coordinator at the Department of Social Services.

Annual Report

To achieve its purpose, the SCFAC shall submit to the Governor and the General Assembly, an annual written report and any other reports prepared by the committee, including, but not limited to, the committee’s findings and recommendations. Annual reports must be made available to the public. The 2019 CDR report is the most recent completed report.

Prevention Initiatives

The SCFAC documents prevention recommendations to be included in the annual report to guide the Governor and General Assembly in prevention initiatives.

An example of the SCFAC’s prevention initiatives include the goal of developing subcommittees for unsafe sleep and suicide child deaths.

Protocols

The SCFAC maintains protocols for confidentiality, governance, and operation.

Training

Professional development of state and local CDR teams continues to be a priority of the SCFAC. It is the goal of the CDR state coordinator to provide training opportunities for local CDR teams.

Last Updated: July 2021

Program Contact

Brittnay Jackson
Strategic Projects Coordinator
Office of Strategic Projects and System Alignment
South Carolina Department of Social Services
1535 Confederate Avenue
Columbia, South Carolina 29201
Phone: 803-315-1353
E-mail: Brittnay.Jackson@dss.sc.gov

Tools

South Carolina Child Fatality Review Legislation

Reports

South Dakota

Program Description

Administration
South Dakota’s child death review extends to all 66 counties in the state. Additionally, there has been no State Level Advisory Group to review statewide data and develop public health recommendations. In 2011 the Governor of South Dakota appointed a Task Force on Infant Mortality that recommended that all infant deaths in South Dakota be reviewed as a strategy to reduce infant mortality.

Teams
South Dakota has two regional teams, East River and West River. The East River team reviews infant/child deaths (post-birth hospitalization) that occur in the 44 counties east of the Missouri River. The West River team reviews infants/child deaths (post-birth hospitalization) that occur in the 22 counties west of the Missouri River. The teams are multidisciplinary and are comprised of volunteers from law enforcement, Child Protection Services, hospital staff, fire departments, emergency medical services, public health, behavioral health, forensic pathology, the Bureau of Indian Affairs, Indian Health Services, the Great Plains Tribal Leader’s Health Board, and the States Attorney’s and U.S. Attorney’s offices.

Regional Teams:
Teams conduct retrospective/periodic reviews.

Reviews
South Dakota Regional teams review all child deaths up to age 12.

Purpose
The purpose of the child mortality review in South Dakota is prevention.

Data
Standardized data reporting forms are completed for all infant death reviews and input into the database from the National Center. Data from death review is shared with the public via published infographics, presentations, and an Infant Mortality Report, developed every 5 years. A data dashboard, maintained by the CDR Epidemiologist, also displays information from both death review and vital statistics on the Department of Health’s website under Infant Mortality.

Reports
An Infant Mortality Report is developed every 5 years.

Prevention Initiatives
Team findings have influenced policy changes in the state. Local communities have initiated “Back to Sleep” campaigns and neonatal MCAD screening initiatives and since 2012, has reviewed post-birth hospitalization infant deaths statewide. Team findings have motivated prevention activities such as lifesaving equipment being installed at a local river park. South Dakota will begin a State Level Advisory Group meeting annually to make statewide preventive and public health recommendations after a review of data collected by the team reviews.

Protocols
South Dakota has protocols for confidentiality at IDR meetings.

Training
No training is offered.

Last Updated: May 2024

Program Contact

Abhinav Datti, MPH, MBBS
Prevention Services Manager
Office of MCH Data and Analytics
South Dakota Department of Health
1501 South Highline Avenue
Sioux Falls, SD 57106
Phone: 605.215.0295
Email: Abhinav.Datti@state.sd.us

East and West Team Chairperson
Dr. Denise Hanisch
Medical Director
South Dakota Department of Health
600 E. Capital Avenue
Pierre, SD 57501
Email: Denise.Hanisch@state.sd.us

Tennessee

Program Description

Administration
The Tennessee Child Fatality Review (CFR) Program was established in 1995. It is housed out of the Tennessee Department of Health, Division of Family Health and Wellness. Tennessee is a member of the Southeast Coalition on Child Fatalities.

Teams
Tennessee has both state and local CFR teams. Both team levels are mandated. There is no official relationship with the Citizen’s Review Panel (CRP); however, a representative from the Department of Children’s Services sits on both the State Child Fatality Review Team and the CRP.

State Team:
The state child fatality prevention team reviews the reports from the local teams, analyzes statistics of the incidence and causes of child deaths and makes recommendations to the Governor and General Assembly to promote the safety and well-being of children.

Local Teams: (Chairperson(s) – Department of Health team leaders)
Local teams have been established in the 31 judicial districts. Retrospective reviews are conducted by these teams.

Reviews
Tennessee reviews all deaths of children 17 years of age or younger.

Purpose
The goals of Child Fatality Review are to improve the response to child fatalities, provide accurate information on how and why Tennessee children are dying, and ultimately reduce the number of child deaths by establishing policies and programs for prevention.

Data
Standardized data reporting forms are completed for all reviews.

Annual Report
The State Child Fatality Review Team reviews the reports from the local teams, analyzes statistics of the incidence and causes of child deaths, and makes recommendations to the Governor and General Assembly to promote the safety and well-being of children. This report is required by statute.

Prevention Initiatives
Tennessee CFR findings have influenced policy changes such as encouraging collaboration between disciplines and autopsy requirements.

Protocols
The Tennessee CFR program has a confidentiality protocol.

Training
New members to local and state teams undergo an orientation session with the Program Director. A training for all child fatality review team members is held annually.

Last Updated: August 2024

Program Contact

Nicole R. Andersen, MPH
Child Fatality Review Program Director
Tennessee Department of Health
Andrew Johnson Tower, 7th floor
710 James Robertson Parkway
Nashville, TN 37243
Phone: (615) 253-2657
Email: Nicole.R.Andersen@tn.gov

Website: https://www.tn.gov/health/health-program-areas/fhw/child-fatality-review0.html

Tools

Tennessee Child Fatality Review Legislation

Reports

Tennessee 2023 Child Fatality Annual Report

Texas

Program Description

Administration
The Texas Child Fatality Review Program was established in 1995 by legislation. In the early years, it has been primarily funded by the Department of Family and Protective Services (DFPS) and the Department of State Health Services (DSHS). However, legislation passed by the Texas Legislature in May 2005 transferred responsibility, including funding, for the program completely to DSHS in FY 2007, where it has remained to the present.

Teams
Texas has both state and local CFR teams.

State Team:
The Texas State Child Fatality Review Team (SCFRT) is comprised of 25 members who meet quarterly. DSHS is responsible for assisting the SCFRT in the establishment and training of review teams, preparation of the Biennial Report, recommendations to the Governor and legislature and support of the activities of the SCFRT.

Local Teams:
Texas has 83 local teams that cover 203 of the 254 Texas counties. There are 51 counties without CFR teams. Local team leadership and membership varies from county to county.

Reviews
The death certificate is the basis for the review and is sent to local team coordinators from the DSHS Vital Statistics. They are accompanied by birth abstracts with medical information on the mother and newborn if the child is under two years of age. Texas teams aspire to review all child deaths under age 18.

Purpose
The purpose of the Texas CFR Program is to improve the response to child fatalities, provide accurate information on how and why Texas children are dying and ultimately reduce the number of preventable child deaths by taking data into prevention practice.

Data
Local teams are responsible for collecting and entering data on the child death reviews into the NCRPCD multi-state online reporting system.

Biennial Report
The Texas Child Fatality Review Coordinator works with other DSHS staff and the SCFRT Committee to write the biennial report. The biennial report is submitted to the Governor and Legislators by April 1 of even-numbered years. The report is distributed to agency heads, child advocacy organizations, the medical community, and to all members of local review teams.

Prevention Initiatives
The SCFRT Committee has actively advocated for the passage of laws that would increase child safety. The SCFRT Committee recommendations have included requirement that all newly built swimming pools have four-sided fencing; that the legal blood alcohol content (BAC) be lowered to zero for those transporting children; that law allowing for parents and guardians to provide driver education to minor children be repealed; and that a birth-match system be created to monitor infants born to parents who had a child die of abuse or whose rights were terminated due to abuse and neglect. Texas Department of Family and Protective Services created Project HIP (Helping Through Intervention and Prevention) in response to the SCFRT recommendation for a birth-match system. In this program, parents who have had their parental rights terminated due to child abuse and/or neglect within the past 2 years and have a newborn child are provided with free and voluntary services to build a positive home environment and prevent child abuse.

In the 2013 legislative session, the SCFRT recommendation about water safety resulted in a resolution to recognize April as Texas Water Safety Month for the next 10 years. The SCFRT Committee has also issued numerous position statements that have been used as the basis for prevention activities: Safe Sleep for Infants, Motor Vehicle Safety for Infants and Children; Water Safety for Children; Child Suicide; Fire and Burn Prevention for Children; Substance Abuse Dependence; Child Suicide, and Addressing Preventable Child Abuse and Neglect. The position statements are posted on the Texas CFR website.

Protocols
Texas has a child death scene investigation protocol in place.

Training
Through the generosity of the Title V program, child fatality review and injury prevention training is provided to the members of the local teams and the members of the State Committee. Historically, the conference is done in conjunction with another agency. Since 2012, the program is in partnership with Prevent Child Abuse Texas to provide annual training. In 2016-2017, local child fatality review teams received training for all team members regionally and Title V sponsored the attendance of two members per local team and of all State Committee members to a statewide injury prevention conference. In 2018, DSHS will sponsor two members per local team and all State Committee members to attend a training/meeting and conference.

Last Updated: November 2019

Program Contact

Sarah Blezinger, MPH
Injury Prevention Coordinator
Department of State Health Services
Office of Injury Prevention
1100 W. 49th Street
Austin, TX 78756
Phone: 214-435-2096
Email: cfrt@dshs.texas.gov

Website: http://www.dshs.state.tx.us/mch/Child_Fatality_Review.shtm

Tools

Texas Child Fatality Review Legislation

Reports

Texas Child Fatality Data and Recommendations 2018

Utah

Program Description

Administration
Child Fatality Review Committee:
Each year around 470 children ages 0-18 die in Utah. In response to these deaths, a few different interagency Child Fatality Review Committees (CFRC) have established by the Utah Department of Health. The first beginning in 1992. The CFRC was charged with the review of the circumstances and cause of all childhood deaths in the state. The purpose of the CFRC is to develop a better understanding of child deaths in order to reduce the number of intentional and unintentional deaths of Utah children.

The goals of the CFRC are to:

Identify and describe the prevalence of risk factors among deceased children by studying and reporting trends and patterns of child deaths in Utah.
Maximize resources through interagency collaboration to identify and describe the service delivery of the involved systems (medical, human services, and law enforcement) to high-risk children, and make policy recommendations to improve the service systems to better meet the needs of all families involved with these systems.
Promote effective prevention strategies to reduce the number of child deaths.
Refer issues and propose strategies to appropriate organizations and agencies to promote education and prevention.

The main CFRC meets once a month to review Utah child deaths from injury related and undetermined causes. These include accidental deaths, homicides, undetermined deaths, as well as any Sudden Unexpected Infant Death (SUID) or Sudden Death in the Young (SDY) deaths.
There is also a separate quarterly review process that focuses on Utah’s youth suicide deaths. This Suicide Child Fatality Review Committee (SCFRC) which includes most of the same committee members as the CFRC was added in 2020 to address the large amount of time being spent each month on youth suicide death, because of the high number and all of the additional information available from the psychological autopsies/next of kin interviews that are done on these cases.

After the initial CFRC review of any SUID/SDY deaths, there is also a quarterly Advanced Clinical Review Committee (ACRC) with a diverse group of pediatric medical experts including neurologists, forensic pathologists, cardiologists, and geneticists/genetic counselors who categorize them and address potential pathologies and genetic issues identified.

Each of these death review processes provide a detailed understanding of how and why child deaths occur in Utah and discuss recommendations prevent future death and injury. The goals of the reviews are to:

Identify the important issues and concerns surrounding the deaths.
Assess the accuracy and completeness of data from death investigations.
Assess the accuracy and completeness of medical data surrounding the deaths.
Improve communication through interagency collaboration of the various health, human services, and law enforcement agencies to ensure that complete and thorough investigations are performed on child deaths.
Refer prevention and policy recommendations to the Child Fatality Action Committee (This committee brings together partners working in prevention from across the state and CFRC members annually to review the recommendations and the aggerate and trend data to identify priories that should be addressed in the state.).

The formation of the different child fatality review committees brings together diverse agencies and organizations that serve Utah children and families. This multidisciplinary approach enables members to share available information from different sources to better understand how and why a child has died. It also helps them understand how their organization can help prevent future death and injury. It is this coordination that improves the process of thoroughly reviewing child deaths and the implementation of prevention recommendations in Utah.

Teams

State Team:(Chairperson – Kacy Robinson)
This team has 34 members. The team meets monthly.

State Suicide CFRC Team:(Chairperson – Michael Staley)
This team has 17 members. The team meets sixteen times a year. The Advisory Committee meets yearly.

State Advanced Clinical Review Committee:(Chairperson – Kacy Robinson)
This team has 20 members. The team meets quarterly.

State Action Committee:(Chairperson – Nathan Malan)
This team has 24 members. The team meets monthly.

Reviews
The Utah State Team conducts a full review on all suspicious, unexplained or unexpected deaths. Additionally, all injury deaths receive a committee review and all death certificates receive a medical review. The team reviews deaths to children age 18 and under.

Purpose
The purpose of the Utah Child Fatality Committee is to investigate child deaths and provide quality assurance and services in order to improve response and prevent future child deaths.

Data
Beginning in 2014, death data is being submitted to the National Center for the Review and Prevention of Child Deaths (NCRPCD). The Department of Health has access to the Office of the Medical Examiner database and the state vital records. These are used on each case to identify data as well obtain information for collection. The Department of Health analyzes the data with SAS.

Annual Report
The Utah Child Fatality Committee produces an annual report. This is distributed to the Child Fatality Committee, local health departments, health department officials, the media, hospitals, libraries and is available on the VIPP website. Fact Sheets are published periodically to inform the public on specific topics in the interim.

Prevention Initiatives
Findings from the review process have influenced policy changes in Utah. These include seat belt/car seat/booster seat legislation, the initiation of a youth suicide study, dating violence protections, among others. Additionally, child fatality review findings have motivated prevention efforts.

Protocols
Utah has several protocols in place including protocols for the CFRC meetings, confidentiality, child/infant death scene investigation and a death certificate review process.

Training
Training is offered as new people join the different committees and as evaluation indicated specific needs or changes to processes.

Last Updated: May 2022

Program Contact

Kacy Robinson
Utah Department of Health and Human Services Violence and Injury
P.O. Box 142106
Salt Lake City, UT 84114-2106
Phone: 435-720-3512 (mobile)

Email: kacymr@utah.gov

Website: http://www.health.utah.gov/vipp/childFatality/overview.html

Tools

Utah Child Fatality Legislation

Reports

Utah Child Fatality Review: Annual Report of 2019 Data

Vermont

Program Description

Administration
In 2018, the Child Fatality Review Team (Team) was written into Vermont Statue (18 V.S.A. § 1561). Vermont has reviewed child fatality for decades. Under statue the Vermont Child Fatality Review Team is provided with an outline of the Team’s purpose, membership, meeting frequency, administrative assistance, access to information and records, limitations, and confidentiality.

Teams
Vermont has one statewide child death review (CDR) team. According to the law, participation is required by several state agencies and departments. Vermont Team membership also includes members appointed by the Secretary of Human Services who are experts in child abuse or neglect, health, social work, child care, education, or law enforcement. The Vermont Team includes experts from different fields who work together to understand child deaths and find ways to stop them from happening in the future. Their work helps improve community health and prevent serious injuries in children.

Reviews
The Vermont Team examines all cases of unexpected, unexplained, and/or preventable child fatality among Vermont children younger than 18-year-old.

Purpose
To review and analyze the deaths of Vermont children to identify system gaps and risk factors associated with these fatalities, educate the public, service providers, and policymakers about unexpected, unexplained, or preventable child fatalities and strategies for intervention, and to recommend legislation, rules, policies, practices, training, and coordination of services to promote interagency collaboration and prevent future fatalities.

Data
Vermont child fatality data is compiled by Team representatives across different sectors including the Office of the Chief Medical Examiner, medical, law enforcement, the Department for Child and Families, the Agency of Education, and the Department of Mental Health. Each representative compiles relevant case information and records to complete the CDR form and develop high-level case summaries to be shared with the larger Team during review. All CDR case data is entered into the National Fatality Review Case Reporting System.

Annual Report
The Child Fatality Review Team Report to the Legislature is submitted to the Vermont General Assembly annually in accordance with Vermont Statute 18 V.S.A. § 1561. The report contains an overview of the Team, key findings and recommendations, summary of yearly activities, planned activities for the upcoming year, and child fatality data.

Protocols
Per Vermont Statue (18 V.S.A. § 1561) the Team’s review process cannot proceed until any criminal prosecution arising out of the child fatality is concluded or the Attorney General and State’s Attorney provide written notice to the Team that no criminal charges shall be filed; and any investigation by the Department for Children and Families is concluded. The Vermont Team has adopted protocols related to CDR form completion, case summary collection, and sudden unexpected infant death case identification, review, and data entry.

Training
The Vermont Team receives training and technical assistance from the Centers for Disease Control and Prevention (CDC) and the National Fatality Review and Prevention. The Team attends the annual CDC SUID Case Registry Reverse Site Visit and hosts annual Vermont Site Visits.

Last Updated: October 2025

Program Contact

Julia Sarrasin
Team Coordinator
Vermont Department of Health
280 State Dr.
Waterbury, VT 05671
Email: Julia.Sarrasin@vermont.gov

Tools

Vermont Laws

Reports

Virginia

Program Description

Administration
Virginia’s Child Fatality Review Program was established by statute in 1994. It has an annual budget of approximately $75,000 that is funded by the MCH Block grant. Funding for the program is on a year to year basis. The program is housed in the Office of the Chief Medical Examiner, which is part of the Virginia Department of Health. There is one paid state CFR employee.

Teams
Virginia has state and regional teams. The Citizen’s Review Panel is included in Virginia’s CDR efforts.

State Team:
The State Child Fatality Review Team is comprised of at least 15 members and meets six times a year. Most of their meeting time is spent reviewing cases. By statute, the team has access to all records related to the decedent child and to the perinatal records of the mother that are related to the decedent child. State team meetings must be advertised as public but are closed when cases are discussed. Before the meeting takes place, state team members are divided into pairs that read individual case files and prepare a case summary document. At the meeting, the pairs present case information to the entire team. The team then determines the degree of preventability of the case and generates ideas for prevention and intervention. The team uses a consensus model to agree on preventability. When the state team develops recommendations, the CFR coordinator calls the agency that the recommendation will affect, discusses the impact of the recommendation on the agency, and reports back to the team. This process supports stronger targeted recommendations.

Local Teams:
There are five regional teams, one in each Virginia Department of Social Services region. The teams meet with varying schedules depending on their individual caseload. By statute, teams invite investigating agencies to attend team meetings to orally present their case file and participate in the team’s review of the case. The regional teams review cases investigated for abuse or neglect by a local department of social services.

Reviews
By statute, the Virginia State Child Fatality Review Team can review the following kinds of deaths to children under 18 years of age: (1) violent and unnatural child deaths; (2) sudden child deaths occurring within the first eighteen months of life and (3) those fatalities for which the cause or manner of death was not determined with reasonable medical certainty. By statute, the Virginia local or regional CFR teams review deaths to children under 18 years of age. The state team does not review all child deaths for every year. Instead, the Virginia state team selects categories of child death (e.g. caretaker homicide or motor vehicle) for each review.

Purpose
The purpose of the Virginia CFR Program is prevention. Teams have always focused on prevention and public health interventions.

Data
Standardized data reporting forms are completed for cases reviewed by regional teams. The State Team does not complete standardized data reporting forms due to the nature of its review process. The collection of data is not required by legislation or policy. Virginia’s CFRT has access to state vital statistics. Vital statistics are used to place reviewed child deaths within the context of all child deaths in the state. CFR data is stored on a computer and is analyzed using SPSS.

Annual Report
Virginia produces a report at the conclusion of each review. This report is distributed to injury prevention groups, domestic violence advocates, police chiefs, sheriff departments, medical examiners, social services directors, child protective services supervisors, members of the Virginia General Assembly, Commonwealth’s Attorneys, SAFE KIDS coalitions, and other child advocate organizations.

Prevention Initiatives
Virginia CFR efforts have influenced policy changes. Statewide examples of this include a legislative changes requiring mandatory stiffer civil penalties for violations of child safety restraint laws where the money from penalties is reinvested into the Child Restraint Device Special Fund, the addition of emergency medical services personnel to the list of mandated reporters, and requiring safe sleep education as part of labor and delivery discharge. Local community examples include community level education on SIDS and co-sleeping, collaboration with Drive Smart Virginia on safe driving among teenagers, shaken baby awareness campaign through a local hospital and collaboration with branches of the military on preventing child abuse and neglect among military families. Examples of how CFR findings have motivated prevention activities include a re-invigorated safe sleep campaign through the Virginia Department of Health, a review of child suicides led to the development of a statewide youth suicide prevention plan and review of caretaker homicides led to an initiative to educate local health department personnel about shaken baby syndrome.

Protocols
Virginia has confidentiality and CFR meeting protocols in place.

Training
Training is provided to new state team members and to any new local or regional child fatality review team as needed or requested.

Last Updated: December 2019

Program Contact

Tricia Smith
Infant and Child Fatality Projects Coordinator
Office of the Chief Medical Examiner
737 North 5th Street, Suite 301
Richmond, VA 23219
Phone: 804-205-3853
Fax: 804-786-1877
Email: tricia.smith@vdh.virginia.gov

Website: http://www.vdh.virginia.gov/medical-examiner/fatality-review-surveillance-programs-reports/child-fatality-review-in-virginia/

Tools

Virginia Child Fatality Review Legislation

Washington

Program Description

Administration

State law (RCW 70.05.170) authorizes Local Health Jurisdictions to conduct child death reviews so that “preventable causes of child mortality” can be identified and addressed. Local Health Jurisdictions are not required to conduct child death reviews.
State law (RCW 70.05.170) requires the Department of Health to:
- Assist LHJs in collecting CDR data and entering it into a database
- Respond to requests for CDR data and share the data to the extent allowable by law
- Provide technical assistance to LHJs and CDR coordinators
- Encourage communication among CDR teams
Conduct these activities using only federal and private funding
In addition to the activities required by law, the Department of Health:
- Serves as a liaison between LHJs and the National Center for Child Death Review, which hosts the multi-state CDR database
- Analyzes CDR data for program planning, evaluation, and reports
- Maintains an electronic mailing list (listserv) to share information with CDR coordinators, CDR team members, and other stakeholders
The Department of Health funds this work through the federal Maternal and Child Health Block Grant.

Teams
Currently, Washington has 7 local CDR teams which are conducted by local public health jurisdictions.

Reviews
Washington CDR teams provide retrospective reviews of all unexpected deaths to children age 17 and under except deaths due to extreme prematurity.

Purpose
The purpose and focus of the Washington CDR process is prevention, not investigation.

Data
Washington State CDR teams participate in the national data collection system administered by National Center for the Review & Prevention of Child Deaths (Michigan Public Health Institute). The State Department of Health provides technical assistance and quarterly data quality/data cleaning.

Annual Report
Washington produces specialized data reports but no annual report. These reports are distributed to a broad range of stakeholders.

Prevention Initiatives
The State Department of Health and local CDR teams are involved in many prevention initiatives. Our Governor issued an executive order on gun safety, including the implementation of a State Suicide Prevention Plan. The State Department of Health is the lead for the implementation of this Plan. We also have a suicide prevention grant from the federal Substance Abuse and Mental Health Services Administration (SAMHSA). Several local CDR teams have been involved in gun safety and safe sleep campaigns. We work with Safe Kids Washington at state and local levels to promote child safety.

Last Updated: March 2019

Program Contact

Peter Agabi
Health Services Consultant – CDR Coordinator
Washington State Department of Health
Office of Family and Community Health Improvement
P.O. Box 47835
Olympia, Washington 98504-7835

Email: peter.agabi@doh.wa.gov

Website: https://doh.wa.gov/public-health-healthcare-providers/public-health-system-resources-and-services/local-health-resources-and-tools/child-death-review-prevention/cdr-program-data-and-resources

Protocols
Local CDR teams are encouraged to follow the protocols in the Program Manual for Child Death Review developed by the National Center for the Review & Prevention of Child Deaths. Confidentiality and data use protocols are outlined in Data Use Agreements with the Michigan Public Health Institute.

Training
The State Department of Health maintains an email list to share information related to Child Death Review and convenes conference calls every other month for local CDR Coordinators. Topics on the conference calls include state and local updates, safe sleep and suicide prevention.

Tools

West Virginia

Program Description

Administration
West Virginia’s CDR Program began as a voluntary process in 1994 and was put into statute in 1996. In 2013 new legislation was enacted and WV Code §61-12A-2 created the Unintentional Pharmaceutical Drug Overdose Fatality Review and combined Child Death Review, Domestic Violence Fatality Review and the Infant and Maternal Mortality Review Teams as one.

Teams
West Virginia Child Fatality Review Team is a state team only.

State Team:

Maggie Molitor: Coordinator, Child Fatality Review Team, Office of the Chief Medical Examiner

Marie Frazier, MD: Pediatric Intensivist from Marshall University

James Kozik: West Virginia State Police, Director of the Crimes Against Children Unit

Corporal Marlene Moore: West Virginia State Police, Crimes Against Children Unit

Michelle Kelly: Medical Social Worker and Case Manager for WVU Hospitals

Jane McCallister: Director of Planning and Quality Improvement, Bureau for Children and Families, WVDHHR

Harry Anderson: Governor’s Highway Safety Program

Lori Bragg-Lawrence: Child Welfare Consultant, DHHR Region 4

Chau’tle Haught: CPS Supervisor, DHHR Region 2

Amanda Gifford: CPS Supervisor, DHHR Region 3

Christa Janes-Ash: CPS Child Welfare Consultant, DHHR Region 1

Melissa Baker: Epidemiologist, Bureau for Public Health

Annette Roberts: Nurse, Bureau for Public Health, Infant and Maternal Mortality Review Team

Patrick Kerr: Licensed Clinical Psychologist, Director WVU Dialectical Behavior Therapy Services

Lisa Carmelia: Administrative Coordinator WV Children’s Justice Task Force

Becky King: Co-Coordinator for Our Babies: Safe and Sound

Kimberly Harrison: Bureau for Behavioral Health and Health Facilities

Lieutenant Mark Davis: Chief Investigator, Upshur Co. Sheriff Department

Matthew Wickert: Director of Operations, Vital Statistics

Allan Casto, Shawn Alderman and Jason Baltic: WV State Fire Marshall Office

Barri Faucett: Director Prevent Suicide WV/Aspen

Ariana Kincaid: Assistant Prosecuting Attorney, Kanawha County Prosecuting Attorney Office

Courtney Rosemond: WV State Fire Marshall Office

Trudi Blaylock: VP Operations PSIMED/Division of Juvenile Services

Vicki Hildreth: Coordinator Emergency Medical Services for Children

Johanna Bosse: Epidemiologist, Child Fatality Review Team, Office of the Chief Medical Examiner

Sarah Ward (Temporary): Data Abstractor, Child Fatality Review Team, Office of the Chief Medical Examiner

Reviews
WV State Code requires basic review and data collection on all child deaths. The West Virginia CDR State Team does a “full” review on deaths that appear preventable– homicides, suicides, motor vehicle, SIDS/SUIDS and accidents and undetermined. Reviews are conducted on children that are less than 18 years old.

Purpose
Review all deaths of children under the age of eighteen years who are residents of West Virginia in order to identify trends, patterns and risk factors; Provide statistical analysis regarding the causes of child fatalities in West Virginia; assist in the promotion of public awareness of the incidence and causes of child fatalities, including recommendations for their reduction; and provide training for state agencies and local multidisciplinary teams as needed.

Data
West Virginia CDR utilizes the National Child Death Review Database and gathers all requested data.

Annual Report
The WV Child Fatality Review Team has completed the annual report for 2017 that includes child deaths from 2015. This report is still under review and has not yet been released. The annual report for 2018 that includes child deaths from 2017 has also been completed and is still under review and has not yet been released.

Prevention Initiatives
Johanna Bosse is working with Vicki Hildreth of EMS-C on their ‘Stay Alive, Just Drive’ campaign about distracted driving. We work closely with Barri Faucett Director Prevent Suicide WV/Aspen to share data so they are able to target their prevention and post-vention efforts.

Training
There have been no recent trainings.

Last Updated: January 2019

Program Contact

Terra Hoff
Fatality & Mortality Review
Program Manager
WV Office of Chief Medical Examiner
619 Virginia St, West
Charleston, WV 25302
Phone: 304-558-6920
Fax: 304-558-7886
Email: Terra.B.Hoff@wv.gov

Tools

West Virginia Child Death Review Legislation

Wisconsin

Program Description

Administration
Wisconsin’s Child Death Review (CDR) Program was established in 1998. There are no statutes or rules promulgated for CDR in Wisconsin. The state CDR Council is housed within the Department of Health Services (DHS) with additional funds from the Centers for Disease Control and Prevention, and the Wisconsin Department of Justice, Children’s Justice Act grant program. Wisconsin is a member of the Midwest Coalition on Child Death Review.

Keeping Kids Alive in Wisconsin was created as the comprehensive CDR state program and grew significantly through a three year grant funded by the UW School of Medicine and Public Health Wisconsin Partnership Program (2008 – 2011). This grant was awarded to Children’s Health Alliance of Wisconsin (Alliance), in partnership with the Injury Research Center at the Medical Center of Wisconsin. Efforts under Keeping Kids Alive in Wisconsin include: development of local CDR teams in Wisconsin counties, support legislation for CDR activities, and increased data collection and analysis. Keeping Kids Alive in Wisconsin: Child Death Review Team Guidelines provides counties with step by step assistance on how to organize and implement a CDR team. Additional technical assistance related to data collection and prevention is also available to teams. Keeping Kids Alive in Wisconsin continues today under partnership and contractual agreement between DHS and Children’s Health Alliance of Wisconsin with funding from Title V MCH, the Wisconsin Department of Justine Children’s Justice Act and the Centers for Disease Control and Prevention.

Wisconsin also participates in the CDC funded SUID and SDY projects. These projects are carried out through a partnership between the Alliance and the Wisconsin DHS. The goal of these projects is to ensure all sudden and unexpected infant and child deaths are comprehensively reviewed by local teams to ensure comprehensive data is collected to inform prevention efforts.

Teams
Wisconsin has a state CDR Council and local CDR teams.

State team: The mission of the state CDR Council is to prevent child deaths and injury in Wisconsin through local multidisciplinary reviews, leading to community prevention. For purposes of the Council, reference to child includes fetal, infant, children and youth. The CDR Council will only review cases when a local team is not in place where the death occurred, or a local team requests a review. Case reviews conducted by the state CDR Council are done so in a deidentified manner. The Council is comprised of 24 members and meets four times per year.

The CDR Council (Council) seeks to:

Facilitate the development of local/regional child death review (CDR) and fetal infant mortality review (FIMR) teams.
Identify training needs and make training resources available to local teams, statewide professional organizations, advocacy groups and others.
Respond to local requests and provide any necessary technical assistance and support.
Review infant and child deaths upon request of a local CDR team, or when a county does not have a team.
Educate the public regarding the incidence and causes of fetal, infant and child deaths, including recommendations that identify needed policy change or action to prevent future deaths.
Provide information to the legislature, state agencies and local communities on the need for modifications to law, policy or practice.
Utilize prevention-focused data analysis to facilitate the above purposes.

Local Teams:
Local CDR teams are county-based. There are 53 local CDR teams in Wisconsin. There are 8 Fetal Infant Mortality Review (FIMR) teams in Wisconsin.

Reviews
Local CDR teams acknowledge and review sudden and unexpected deaths of infants and children. Most local teams complete reviews for infants and children ages 0-18. CDR teams are encouraged to follow the model proposed in Keeping Kids Alive in Wisconsin: Child Death Review Team Guidelines. This model is based on the Maternal Child Health (MCH) National Center for Child Death Review framework.

Local FIMR teams review fetal and infant deaths that meet the FIMR criteria. All Wisconsin review teams are working toward increasing communication and collaboration.

Purpose
The primary purpose of the Wisconsin CDR program is to prevent future deaths. Local CDR Teams strive to uncover the risk factors and circumstances contributing to the death of a child. Local teams utilize the information to target prevention activities.

Data
Wisconsin urges all local CDR and FIMR teams to enter data into the National MCH CDR Case Reporting System. Technical assistance is available to local teams to assist with database training, access and data analysis.

Annual Report
Wisconsin released Sudden Unexplained Infant Deaths (SUID) Report in 2017 to share 2015 SUID data. An updated SUID report was released in 2019.

Prevention Initiatives
Several local CDR teams are partnering with community organizations to implement prevention activities.

Protocols
Keeping Kids Alive in Wisconsin: Death Review Team Guidelines have been developed and are available online at http://www.chawisconsin.org/documents/IP3KKAGuidebook.pdf. Hard copies can be obtained by contacting Karen Nash at (414) 337-4567 or knash@chw.org.

Training
Annual statewide training occurs every fall, bringing together most local review teams. This training focuses on improving quality of reviews, sharing new information and networking. Regional and local trainings are held yearly.

Last Updated: February 2019

Program Contact

Karen Nash
Project Manager
Children’s Health Alliance of Wisconsin
6737 W. Washington St., Suite 1111
West Allis, WI 53214
Phone: 414-337-4567
Fax: 414-266-4876
Email: knash@childrenswi.org

Catheryn Morateck, MPH
Epidemiologist
Children’s Health Alliance of Wisconsin
6737 W. Washington St., Suite 1111
West Allis, WI 53214
Phone: 414-337-4568
Fax: 414-266-4876
Email: cmorateck@childrenswi.org

Website: http://www.chawisconsin.org/injury-prevention-death-review.php?pg=12

Tools

Reports

Wyoming

Program Description

Administration
The Wyoming Child Death Review and Prevention Team was established by the Department of Family Services in December 1997, under the authority provided in the Child Protective Services Act, W.S. 14-3-201 through 14-3-215. The program is funded through the Children’s Justice Act.

Teams
A state team is mandatory.

State Team Chairperson: Brenda Burnett; Co-Chair: Jennifer Zenor

Reviews
In March 1999, the team was expanded to include review of major injuries. Major injuries and fatalities are reviewed if the Department of Family Services had custody of the child. Wyoming has an exclusive focus on maltreatment cases. Currently, there is proposed legislation to expand the review process to include all child deaths and major injuries, not just abuse and neglect.

Purpose
The Vision of the WYRPVT is “To eliminate child major injuries and fatalities in Wyoming.” The Mission statement is: We seek to improve Wyoming’s prevention of and responses to major injuries and fatalities of children. We make recommendations for change through prevention, intervention, training, education, legislation and public policy.”

Data
Data collected during the review process comes from police reports, coroner’s reports, medical reports, DFS investigative reports and others. As of 2007, Wyoming is utilizing the web-based CDR Case Reporting System through the National Center for the Review and Prevention of Child Deaths.

Annual Report
An annual report is submitted to the Department of Family Services by Wyoming Citizen Review Panel.
An independent report is also created for state-wide stakeholders such as the governor’s office and human service agencies.

Protocols
Wyoming has team meeting protocols in place.

Training
Training occurs within the group every year for all members relating to various causes of child deaths and trends in serious injury in children.

Last Updated: February 2017

Program Contact

Brenda Birkle
Wyoming Citizen Review Panel
Email: bbirkle@wycrp.org

Program Website Information

Website: http://dfsweb.state.wy.us/CMI/cmi.html and http://www.wycrp.org

Tools

Wyoming Child Major Injury/Fatality Review Legislation

District of Columbia

Program Description

Purpose
The purpose of the DC CFR Committee is to prevent child deaths and improve child, youth and family service delivery systems.

Protocols
The DC CFR has meeting and confidentiality protocols in place.

Training
Training is offered to new members on the review process. The staff of the CFR program provides this training.

Last Updated: March 2018

Program Contact

Website:http://obc.dc.gov/obc/cwp/view,a,3,q,521195.asp#childfatality