The National Center for Fatality Review and Prevention

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