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
Tools
Reports