text:
1 in collaboration with the
R November 15, 1992 w
G o v e r n o r
TO: Interagency Child Fatality Review Task Force Members
Other Interested Persons
FROM: Bev Ogden, Assistant
Governor's Office for Childr
DATE: November 20, 1992
Last Monday, on schedule, your report was delivered to the Governor, the President of
the Senate and the Speaker of the House.
You should be very proud of the work you have accomplished during the year long
effort to gather information, resolve issues around the interagency coordination of
cases, and set the direction for the drafting of the report.
While our work was in the final stages, a tragic alleged child abuse homicide in
Phoenix brought public and media attention to the work of our Task Force. I have
included two of the articles which appeared on the front pages of the Arizona Republic
and the Phoenix Gazette for three days in late October and early November. While
we began our work knowing that Arizona had serious deficiencies in the systems
involved with an unexpected child death, we hoped our efforts would be in time to
prevent such a sorrowful event. Although we cannot change the reality of these
deaths, we can rededicate our efforts to prevent any reoccurrence of this tragedy.
The legislation to implement the recommendations of the report is being drafted and a
file has been opened at the Legislative Council. A meeting of the Task Force will be
called before the 1993 Legislative Session begins to plan strategy for the passage of
the State Child Fatality Team bill.
We have a good supply of reports. If you can use additional copies for others in your
agency or organization, please call me at 542-3191.
As coordinator of your Task Force, and on behalf of our co-chairs, Susan Burke and
Marsha Porter, I thank you for your exceptional dedication, hard work and cooperation.
We are pleased to be able to continue this association as we promote the passage of
the bill and oversee the formation of the State Child Fatality Review Team.
Governor's Office for Children, State Capitol, West Wing, Room 404, Phoenix, AZ 85007
(602) 542-31 91
November 15, 1992
This year more than 1,000 Arizona children will die. That much we know.
We will know very little, however, beyond the cold facts on the death certificate, about how they
died, why they died, and how their deaths could have been prevented.
We know some will die at the hands of those they love and trust, their parents and caretakers.
Some will be children whose families have slipped between the cracks of our fragmented social
and health service delivery systems. Many deaths, clearly, could have been prevented,
avoiding the sorrow that falls upon parents, grandparents, neighbors, friends and caregivers
when a child dies.
Our State is about to embark on the long and difficult process of identifying the nature and the
causes of these deaths. We can do no less remembering the children who have died and those
who are at risk of early and tragic death.
The Interagency Child Fatality Review Task Force has dedicated this past year to examinin the
wnrk of other states and assessing .Arizona's &i!ity to respond. The members are indivi 8 uals
who care for, serve and advocate for the children of Arizona. They believe strongly in the
preventability of early childhood deaths. TheK are willing to dedicate their time -- their eneriy --
their experience -- to guide this State throug the process described in this report. They wi not
cease their efforts until every unexpected child death is examined -- until we know why these
children are dying and what can be done to prevent these tragic deaths.
We expect you will share our dedication to saving children's lives. It is time to join together to
commit the resources of state and local agencies, professionals and private citizens to reduce the
incidence of preventable child deaths. As individuals, professionally and personally, we can
make a difference. The process is set forth in this report. The resource needs are small. The
rewards will be priceless.
Marti Lavis
Director ~ssistajiDt irector
Presented by the
Arizona Interagency Child Fatality Review Task Force
in collaboration with the
Governor's Office for Children
Arizona Department of Economic Security
Arizona Department of Health Services
Presented to
The Honorable Fife Symington, Governor, State of Arizona
The Honorable Peter Rios, President, Arizona State Senate
The Honorable Jane Dee Hull, Speaker, Arizona State House of Representatives
November 15, 1992
The Governor's Office for Children
1700 West Washington, Room 404
Phoenix, Arizona 85007
(602) 542-31 9 1
and Task Force Co-chairs
Marsha Porter and Susan Burke
gratefully acknowledge the contributions of
The sponsors of H.B. 2362, Chapter 124, Laws of 1991:
Honorable Nancy Wessel
Honorable Debbie McCune Davis
who believe the State must act on behalf of our children who die,
and those who are still at risk.
The agency directors in 1991 who initiated this project:
Toni Neary Harper,
Ted Williams, and
Linda Moore Cannon
who gave strong support to the legislation and the initial work of the Task Force.
The following individuals who joined with Task Force members
to lend their expertise to the work of the
Task Force Subcommittees:
Don Allen
Anna Arnold
Russel A. Boshart
Erica DrewB ?do rnell
Karen Diaz
Jan Emmerich
John Goad
Janice Guenero
Nancy Jonap
Bill Leonhard
Debby Perry
Beth Rosenberg
Catherine M, Schuyler
Polly Sharp
Darrell Smith
Ann Tarpy
TO B.J. Tatro, the Task Force Consultant;
Janet Wise and Elizabeth Brink, Governor's Office for ChildrenStaff; and,
Above all, the members of the Interagency Child Fatality Review Task Force whose
extraordinary commitment to working through the issues presented by this task led to its
successful completion.
Children in our society are special gifts. We must nurture our children,
show them respect and protect them to the best of our ability.
Any less w!II result in the destruction of our society.
- Snohomish County, Washington
Judge Joseph Thibodeau, explaining
his decision at the sentencing hearing
of a defendant convicted of killing her
adopted daughter.'
Executive Summary .......................................................... i
Statement of Need ............................................................ 1
Introduction ........................................................... 1
Scope of the Problem ...................................................5
Response to the Need ......................................................... 10
In Other States ......................................................... 10
In Arizona ............................................................. 12
Current Status of Child Fatality Review in Arizona ....................... 23
Child Fatality Review and Prevention Plan ..................................... 24
State Team ............................................................. 26
Local Teams ........................................................... 30
Confidentiality ........................................................ 35
Data Collection ........................................................ 38
Prevention ............................................................ 40
Required Funding ........................................................... .44
Appendix A: Interagency Child Fatality Review Task Force Members .............. 47
Appendix B: Data Sets ......................................................... 51
Appendix C: Article by Dr. Michael Durfee ...................................... 54
The death of a child is a tragic event. A death is even more tragic when it could have been
prevented. Perhaps the most tragic of all are those deaths attributable to child abuse or
neglect or those in which there are unanswered questions about how and why the child
The fact is that too many of Arizona's children are dying. Our rate of death for children ages
1-14 ranks Arizona as the sixth highest in the nation. Our rate of violent death for teens
ages 15-19 ranks Arizona as the ninth highest in the nation.
Information regarding the causes of death of Arizona's children and risk factors present in
the lives of children who die unexpectedly is very limited. The cause of death as recorded
on the death certificate is reported to the Arizona Department of Health Services, but
national studies and our review have shown that information recorded on death
certificates is often inaccurate or incomplete. For example, deaths due to child abuse or
neglect often go undetected because death investigations, when they occur, have not
focused on the possibility of child maltreatment as a potential cause of death and because of
lack of an adequate autopsy by a trained forensic pathologist.
In Arizona, no single agency tracks all child deaths and assesses the circumstances
surrounding those that were unexpected. Many agencies have a role in child fatality
response, but there is no system for coordination and communication among agencies.
There is no agency charged with the identification of risk factors. Early identification of risk
factors through a systematic death review process followed by measures to eliminate or
reduce these risks is the key to successful prevention.
In response to the growing concern about the welfare of Arizona's children, the Legislature
passed legislation in 1991 requiring the Governor's Office for Children, in cooperation with
the Arizona Department of Economic Security and the Arizona Department of Health
Services, to establish an Interagency Child Fatality Review Task Force. The Task Force was
charged with developing a state plan for systematic, multidisciplinary, multiagency review
of child fatalities in Arizona, and for interdisciplinary training and community education
aimed at reducing preventable child fatalities.
The Task Force was broadly representative of all the disciplines, agencies and interests on
the local, state and federal levels, including tribal entities, within Arizona. The
multidisciplinary, multiagency commitment to collaboration was essential to the success of
the Task Force's efforts and will continue to be critical to the success of this plan.
The Task Force studied the most effective ways to reduce preventable child fatalities. These
1) Identifying the actual cause of death through a multiagency investigation,
autopsies performed by skilled forensic pathologists, and communication among
agencies involved with the child and family;
2) Taking action at the individual case level based on an analysis of the
information, e.g., prosecution of perpetrators in cases of homicide and services to
families at risk;
3) Identifying risk factors;
4) Setting policies to improve detection of the true cause of death and response;
5) Developing prevention strategies, including professional training, education and
community mobilization.
The Task Force learned that half of the states have already established systematic death
review processes, either at the local or state level, or both. The trend is toward establishing
both state and local teams. Local, multidisciplinary, multiagency teams are typically
convened to review individual cases of unexpected child deaths. They collaborate to
identify any previously undetected child maltreatment related homicides, and to identify
needed intervention or prevention services.
Additionally, the local teams collaborate to identify any service gaps or changes in agency
practices at the local level and to develop local prevention and education strategies. The
focus is on improving system response and preventing child fatalities. State teams typically
have a broader, policy focus. They, too, have multidisciplinary and multiagency
representation. They identify trends in child fatalities and risk factors; recommend changes
in agency policies and practices; and, bring together interested parties to design and
implement strategies to reduce preventable child fatalities.
It is time for Arizona to join in the national effort to reduce preventable child fatalities. It is
time to initiate a statewide systematic, multidisciplinary, multiagency approach to the
review of all child deaths. It is time to create a statewide structure that promotes
collaboration and leads to better response to child fatalities, and, ultimately, to prevention.
In order to reduce the number of preventable child fatalities in Arizona, the Interagency
Child Fatality Review Task Force strongly recommends the following actions:
Adopt a plan for the systematic review of all child fatalities in Arizona.
* Establish a multiagency, multidisciplinary State Child Fatality Team by January
1994 to identify and address policy issues, and to guide prevention, education and
training efforts based on their findings.
Establish multiagency, multidisciplinary local child fatality review teams by
January 1995 to review individual child fatalities, to make recommendations for
improved systems response, and to provide advocacy at the local level.
Examine existing protocols and policies of the medical examiner, hospitals and
other medical institutions, law enforcement and social services systems to assess
their adequacy and uniformity in responding to child fatalities. The Task Force
shall make recommendations, where indicated, to federal, state and local
agencies on systems improvement.
Adopt or amend legislation to promote the confidential sharing of information
required for comprehensive review and investigation of child abuse and neglect
fatalities among agencies participating in the child fatality review teams.
Provide interdisciplinary professional training and community education that is
developed and implemented in a collaborative manner by all agencies and
organizations involved in and concerned about child fatality prevention and
Develop and implement child injury and death prevention strategies, with
leadership from the State Child Fatality Team and local teams, in collaboration
with agencies, organizations, and local community members.
Continue the Interagency Child Fatality Review Task Force until such time as
the State Team is fully functioning, for purposes of oversight and consultation.
The death of a child strikes at the heart of a family and a community. Simply
put, in this society, children are not supposed to die, and when a child does
die, we are faced with the most undesired of mysteries and the loss of a part of
our future. The pain, the anger and the blame that often accompany a child's
death increase when the child's death is from a preventable cause,
particularly when that cause is associated with child abuse or neglect, or when
the community's concerns and questions about the death are not adequately
-Sarah R. Kaplan
American Bar Association2
Why does Arizona rank 46th in the nation in child death rate? Only South Carolina, the
District of Columbia, Arkansas, Alaska and Mississippi have higher death rates for children
ages 1-14.3 If we knew WHAT HAPPENED and WHY, we could use this information to
improve our performance. Even if we were only able to move Arizona up to the national
average, we would be saving the lives of more than 52 children each year.
Why does Arizona rank 43rd in the teen violent death rate? Only Oklahoma, Wyoming,
West Virginia, Arkansas, New Mexico, Nevada, Alaska and the District of Columbia have
higher violent death rates for teens ages 15-19.4 If we knew WHAT HAPPENED and WHY,
we could use this information to improve our performance. Even if we were only able to
move Arizona up to the national average, we would be saving the lives of more than 45
children each year.
Why are our children dying? Are the deaths due to disease, suicide, homicide or injuries?
How many deaths could have been prevented?
All we know now is the cause of death as stated on the death certificate. Experts across the
country tell us that this information is not always complete or even accurate. Many child
deaths are misdiagnosed and mislabelled, particularly when the death is due to child
maltreatment (abuse or neglect).
The consensus is that the information we have now is simply not enough. We must know w
WHAT HAPPENED and WHY in order to prevent child fatalities. Furthermore, we must rn
work together and use this information to carry out strategies which have been found
effective in reducing preventable child deaths. Early identification of risk factors through a
systematic death review process followed by measures to eliminate or reduce these risks are m
the keys to successful prevention. rn
Early identification of risk factors through a systematic death review
process followed by measures to eliminate or reduce these risks are
the keys to successful prevention.
The case of child drownings is an excellent example of how successful we can be in
preventing child fatalities if we collect and analyze information regarding causes and work
together to take action. The rate of death from drowning among Arizona's children ages 1-4
decreased from a high of 19.5 in 1981 to 5.8 (per 100,000) in 1990.5 (See Figure 1.) This came
on the heels of a community wide media campaign, coupled with changes in local
ordinances governing pool enclosures. Referring to the decrease in the number of total
drowning incidents in the city from 1989 - 1991, City of Phoenix Fire Department Division
Chief Doug Tucker stated in a memo dated January 1,1992:
While we would still like to bring these numbers lower, it is important to
note that the drowning experience this year and in 1990 is markedly lower
than 1989 when the "Just A Few Seconds" campaign was initiated. The 1989
rate of 101 dropped to 48 in 1990. When the rate drops more than half (53%),
we feel we have behavioral change, not just luck.
In 1991, confronted with the questions: "Why are Arizona's children dying?" and "What
can we do to prevent child deaths?", the Arizona State Legislature passed Chapter 124, m
Number of deaths per 100,000 children 1-4 years old:
21 -
MOTOR-V€HtCCE- R E LAT E D
1 <
1980 1981 1 982 1983 1984 1985 1986 1987 1988 1989 1990
House Bill 2362. The bill called for the creation of an Interagency Child Fatality Review Task
Force and charged the Task Force with the development of a state plan "for identifying and
reviewing unexplained and unresolved child fatalities for the purpose of determining and
reducing the number of preventable child deaths." This plan is the result of the work of the
Task Force and, as provided in the bill, is being submitted to the Governor, the President of
the Senate and the Speaker of the House of Representatives.
In the following pages, this plan sets forth a statewide process for:
Identification and review of all child (ages birth to 18) deaths;
State-level multidisciplinary, multiagency review of all unexpected child deaths
for purposes of prevention and education;
Local-level multidisciplinary, multiagency review of all unexpected child deaths
for purposes of case coordination, prevention and education;
Interdisciplinary professional training and public education designed to reduce
the number of preventable child deaths in Arizona;
Design, evaluation and dissemination of information on "best practices"
regarding strategies to prevent child fatalities, including community
mobilization; and,
Collaboration among all parties concerned with reducing preventable child
One of the primary reasons for the implementation of child fatality review teams
throughout the United States has been to identify and ultimately prevent child deaths
caused by abuse and neglect. This plan, however, calls for a broader death review process
that addresses all preventable child deaths from a public health perspective.
A preventable child death is defined as "one in which, with retrospective analysis, it is
determined that a reasonable intervention (e.g., medical, educational, social, legal or
psychological) might have prevented the death. Reasonable is defined by taking into
consideration the condition, circumstances or resources available."6
A preventable child death is defined as "one in which, with
retrospective analysis, it is determined that a reasonable
internention (e.g., medical, educational, social, legal or
psychological) might have prevented the death. Reasonable is
defined by taking into consideration fhe condition, circumstances or
resources available."
In the United States, 9.8 out of every 1,000 infants died prior to their first
In Arizona, 9.2 per 1,000 died.
In the United States, 32.4 out of every 100,000 children ages 1-14 died.
In Arizona, 39.1 per 100,000 died. I
In the United States, 69.3 out of every 100,000 teens ages 15-19 died violent
In Arizona, 86.6 per 100,000 died.7
In 1990, according to the Arizona Department of Health Services@
602 Arizona infants died before their first birthday. The five leading causes of
infant deaths were: perinatal conditions such as low birthweight or short
gestation, congenital anomalies such as circulatbry system irregularities, Sudden
Infant Death Syndrome (SIDS), accidents/adverse effects, and infectious and
parasitic diseases.
258 Arizona children between the ages of 1-14 years died. The leading causes of
death for children ages 1-14 were: unintentional injuries (particularly motor
vehicle related and drowning), malignant neoplasms, congenital anomalies,
homicide, and infectious and parasitic diseases.
236 Arizona teens between the ages of 15-19 years died. The major reasons for
death were: unintentional injuries (predominantly motor vehicle related),
suicide, homicide, malignant neoplasms, and heart diseases.
How many deaths of children were unexpected? How many deaths were inadequately
investigated and incorrectly labelled? How many of these deaths could have been
prevented? These questions haunt the people who care about our children-- parents, child
advocates, and professionals in the fields of social services, education, health care, public
health, law enforcement and the justice system.
Among the most dramatic and emotionally-charged preventable child deaths are deaths
due to child abuse and neglect. According to the National Committee for Prevention of
Child Abuse which conducts an annual state survey, deaths due to child abuse increased
from 1.4 per 100,000 children in 1985 to 2.15 per 100,000 in 1991- an increase of 54 percent.
Throughout the United States in 1991, an estimated 1,383 children died from abuse or
neglect- almost four per day. 9
This increase is echoed by the National Center on Health Statistics, which reports that the
United States homicide rate (including fatal child maltreatment) for children under one-year-
old rose 55 percent between 1985 and 1988, climbing from 5.3 per 100,000 children to 8.2
per 100,000.lo
And these numbers reflect only the cases where the cause of death is known to be related to
child maltreatment.
Many child deaths caused by abuse and neglect are not reported as homicides. They may be
reported as accidents and may even appear to have been accidents. Some may be reported as
deaths due to natural causes, when abuse or neglect by the caregiver was the real underlying
Many child deaths caused by abuse and neglect are not reported as
homicides. They may be reported as accidents and may even appear
to have been accidents.
Shaken baby syndrome is one lethal example of abuse which can easily be mistaken for a
viral illness, according to pediatric experts.11
Experts estimate that the child homicide rate is underreported in the United States by at
least 20 percent.12 Many factors contribute to the underreporting. These include:
Lack of awareness of child abuse and neglect as the cause of death during the
death investigation;
Varying skills and procedures among physicians, medical examiners and
Incomplete or inaccurate reporting on death certificates; and,
Lack of communication among agencies involved in a possible child homicide.
Experts agree that autopsies are often critical to detecting and prosecuting child abuse related
deaths. In a recent study of active surveillance of child abuse fatalities, Patricia Schloesser et
al. reported that in nearly 90 percent of the cases they studied, the cause of death was
discovered or confirmed by an autopsy. 13 Yet autopsies are not always conducted in cases
where a child dies unexpectedly. The Gannett News Service survey of death certificates for
nearly 50,000 children under age nine revealed that the rate of autopsies varied widely from
state to state, ranging from 29 percent in Mississippi to 67 percent in Rhode Island.14
Arizona currently does not require autopsies in all cases of unexpected child deaths.
Furthermore, Arizona does not have a forensic pathologist in each county of the state. Only
Maricopa and Pima counties have full-time forensic pathologists. Counties that contract for
pathology services (typically from a hospital pathologist) include: Cochise, Coconino,
Mohave, Yavapai and Yuma. The remaining Arizona counties contract with a physician,
typically a local family practitioner, who does not perform autopsies but rather makes the --
decision about whether to send the deceased person out of the county to a pathologist.
Experts agree that having access to experienced medical examiners with specific training in
the area of potential child abuse and neglect deaths is critical in detecting maltreatment
related deaths.
Arizona, like many other states, does not have accurate statistics on the number of deaths
resulting from child abuse and neglect. Deaths resulting from child maltreatment may not
even be reported to the Arizona Department of Economic Security, Child Protective
Services unless there is another child who is vulnerable to child abuse or neglect in the
household. In one recent sensational murder case which captured the news headlines, the
death was never reported to Child Protective Services. The agency learned of the death
through public media.
Only those deaths which are reported to Child Protective Services are counted and reported
to the National Committee for the Prevention of Child Abuse. Given the lack of a clearly
defined child death reporting process in Arizona, is it any wonder that professionals in the
field believe that for every reported child abuse and neglect death, as many as three deaths
go unreported?
In addition to reporting issues, there are other reasons for the lack of good information
related to child fatalities. Lack of coordination among agencies and professionals involved
in child deaths has been noted throughout the United States and in Arizona as well. There
are multiple agencies which may be involved: Child Protective Services, law enforcement
personnel, a medical examiner, prosecutors, public health nurses and other health care
providers, tribal officials and others. Often a child may have been known to several
agencies prior to death, but the death is not brought to their attention. Had the agencies
known, it is likely that they could have cast some light on the situation, perhaps alerting
authorities early on to the possibility that a homicide may have occurred and gone
undetected. Furthermore, through collaboration, these agencies could design and
implement prevention and education programs designed to reduce the number of children
who die needlessly in our state. I
Violent deaths unrelated to child abuse, such as gang-related homicides, are a leading cause
of death among teens in the United States. While there has been an encouraging downward
trend in the child death rate for infants and children ages 1 to 14, teens continue to die in
record numbers in this country. The teen death rate from accidents, homicide and suicide
increased 11 percent from 1984 to 1989 in the United States.15 Arizona experienced a slight
decrease during this time period, although remaining far worse than the national average.16
When, for whatever reason, children are harmed or at risk, someone has
failed them ... Society must not also fail them.
- American Humane Association
In the 1980s, national child welfare organizations and child care workers were turning their
attention to the problems of unexpected child fatalities. A chorus of questions around
highly sensational cases of undetected child abuse deaths led to an examination of
investigation procedures and reporting practices among the agencies involved.
In 1985, the National Committee for the Prevention of Child Abuse initiated an annual
state survey of reported child abuse and neglect fatalities. The purpose of this annual survey
is to provide data which can be used to monitor the number of child maltreatment
fatalities. The data can also be used to identify strategies to prevent child abuse fatalities.
In response to growing concern, Gannett News Service researched the issue and produced a
series of articles that further heightened awareness about child maltreatment related deaths.
The articles cited numerous examples of initially undetected maltreatment fatalities which
were later identified and which could have been detected with thorough forensic autopsies
and skilled death investigations. Additionally, the authors cited the efforts of several states
to mandate autopsies in all sudden and unexplained child deaths and the formation of
death review committees to scrutinize the handling of child death cases.17
Multiagency, multidisciplinary child fatality review teams, such as those cited by Gannett,
have been increasing in number both at the state and local levels. The first was organized in
1978 in Los Angeles; most teams have been formed since 1988.18 According to Michael
Durfee, M.D., co-chair of the Los Angeles County Inter-Agency Council on Child Abuse and
Neglect and a leader in the field of child fatality, as of June 1992, there were child fatality
review teams in 26 states serving 112 million people, which is more than 45 percent of the
nation's population. (See Figure 2.)
Figure 2
Criminal Justice, Social Services, Health L
. sta te Team
Multiagency Peer Review Local Team Only
Inclusive Case Intake C] No Team
Phone Survey - Michael Durfee M.D. - July 8, 1992
The American Bar Association's Child Maltreatment Fatalities Project has been actively
involved in collecting and disseminating information to guide the development of teams,
data collection and investigative procedures. Core team members of child fatality teams
typically include the coroner/medical examiner, law enforcement, prosecuting attorney,
child protective services and health (pediatrician, public health nurse or public health
administrator). Additional members may include schools, preschbols, probation, parole,
mental health, child advocates, fire department, emergency medical technicians and
emergency room staff.
In his survey, Dr. Durfee reported that cases reviewed by the teams are typically chosen
from medical examiner or public health records. Most cases reviewed are very young
children, half under one year of age. The most common cause of death reported is head
trauma followed by other causes such as smothering, drowning, abdominal trauma, burns,
poisoning and traumatic deaths involving weapons.
Dr. Durfee has found that systematic, multiagency review of child fatalities provides built-in
"peer review [that] makes the team more vigorous and more accountable. The
interagency cooperation that develops provides a framework for more competent case
management with non-fatal cases and a framework for future multiagency prevention
programs."l9 The focus of the teams is not to affix blame, but rather to improve
intervention and, ultimately, prevention strategies.
Child fatality review teams have been formed at both the state and local jurisdictional
levels. The trend, according to Dr. Durfee, is toward establishing both state and local teams.
Local teams often focus on case management and services to families, while state teams
focus on policy issues. Both have an active role in improving interagency coordination and
The death of a child is always a tragedy. In Arizona, over one thousand such
tragedies occur each year and our child death rate is one of the highest in the
country. Many of these deaths are potentially preventable, including deaths
due to injuries, abuse, homicide, suicide and unrecognized medical
conditions. However, we cannot begin to take action to curb these deaths
until we know who is dying, where they are dying and why. This is the
purpose of a child fatality review team: to provide the facts surrounding
childhood deaths so that appropriate action can be taken to prevent
reoccurrence of such tragedies.
- Mary Ellen Rimsza, M.D.
President, Arizona Chapter
American Academy of Pediatrics
Arizona, like many other states, has identified the need to address the issue of unexpected
child deaths. Several agencies and organizations have been actively involved, although
efforts have not always been coordinated.
The agencies and organizations currently involved and required to participate in the
review or prevention of child fatalities include the following:
Governor's Office for Children. Under Executive Order No. 88-2, the Governor's Office for
Children is charged with serving as an interagency coordinator of children, youth and
family programs within state government; promoting coordination with federal and
private agencies; recommending priorities for children and youth services to the Governor;
organizing community efforts on a statewide level around children and youth issues of
statewide concern; and, providing an advocacy voice for children and youth in state policy-making.
A central focus is the promotion of the strength and well-being of Arizona's
Arizona Department of Economic Security. The Department is responsible for receiving
reports of dependent, abused or abandoned children and investigating to determine if any
child is in need of protective services (Arizona Revised Statutes 5 8-546). Additionally,
internal procedures outline the process for investigating the death of any child in the care,
custody or control of the Department, or who resides in a Department-operated or
supported residential setting, or who dies while in a program operated, funded or licensed
by the Department (DES-1-07-02).
Arizona Department of Health Services. Through its Office of Women's and Children's
Health, the Department is responsible for public health including the prevention of
childhood death. Through its Office of Vital Records, the Department is responsible for
reviewing and maintaining records of all Arizona deaths. The Office of Planning and
Health Status Monitoring is responsible for analyzing and disseminating statistical
information regarding deaths in Arizona. Both the Division of Behavioral Health Services
and the Office of Child Day Care Licensure require reporting of child deaths in licensed
County Health Departments. County health departments play an important role in the
prevention of child deaths. Additionally, county medical facilities such as Maricopa County
Medical Center notify the medical examiner when a child dies in outpatient facilities or is
dead on arrival at the facility. Unexplained or suspicious deaths as determined by history
and/or physical exam, or those where the findings are not consistent with history, are
reported to Child Protective Services and the local police department. At the Maricopa
County Medical Center all pediatric deaths are reviewed under the auspices of the Pediatric
Department Quality Improvement Committee. The facility's policy is to request an autopsy
on all pediatric deaths.
Law Enforcement and Medical Examiners. Arizona Revised Statutes 9 11-593 requires any
person having knowledge of the death of a human being under certain circumstances to
promptly notify the nearest peace officer of all information in his/her possession regarding
the death and the circumstances surrounding it. The peace officer is in turn required to
promptly notify the county medical examiner and to initiate an investigation of the facts
and circumstances surrounding the death and report the results to the medical examiner. If
there is no county medical examiner, the county sheriff is to be notified and the sheriff is
required to secure a licensed physician to perform the medical examination or autopsy.
Further, Arizona Revised Statutes 5 11-594 directs that the county medical examiner will be
responsible for autopsy when the death occurred under the above referenced circumstances,
and for certifying to the cause and manner of death following a medical examination,
autopsy or both. The medical examiner executes a death certificate indicating the cause and
manner of death. He or she notifies the county attorney when death is found to be from
other than natural causes, and notifies the appropriate law enforcement agency if further
investigation is necessary.
County Attorneys. County attorneys are responsible for reviewing police reports for possible
homicide filings, filing charges, prosecuting homicide cases, and, at the option of the county
attorney, assisting law enforcement with death scene investigations and medical interviews
to ensure that all relevant inforrna tion is gathered.
Arizona Office of the Attorney General. An Assistant Attorney General is involved in the
Arizona Department of Economic Security death closure procedure. The attorney receives a
. copy of all unusual incident reports on deaths or serious injury to children in the care,
custody and control of the Department, or who reside in a Department-operated or
supported residential setting, or who die while in a program operated, funded or licensed by
the Department, and may be involved in requesting an internal investigation. The attorney
participates in the Department's Death Closure Committee which reviews reports of
fatalities. Additionally, the office has prosecutorial functions and handles a substantial
number of appellate actions.
United States Attorney. The United States Attorney is involved in the prosecution of a
child fatality when it is determined to be a federal violation. Examples include cases in
which the crime occurred on an American Indian reservation, or cases in which a crime
was committed across jurisdictional lines, such as across a state border.
Other. Arizona Revised Statutes § 36-2291 (S.B. 1295) which was passed in the 1992 regular
session of the Legislature and which takes effect December 31, 1992, relates to child deaths
attributable to Sudden Infant Death Syndrome (SIDS). The bill requires that all professional
firefighters, certified emergency medical technicians, and law enforcement officers complete
a SIDS training course as part of their basic training. It further directs county medical
examiners or licensed physicians performing the duties of a county medical examiner to
perform autopsies in the case of sudden and unexplained infant death using a protocol
adopted by the Director of the Arizona Department of Health Services. A committee is
established to make recommendations regarding the protocols, including standards for
death scene investigation, data requirements, criteria for determining cause of death, and
criteria for specific tissue sampling. The bill also establishes a Sudden Infant Death
Advisory Council appointed by the director of the Arizona Department of Health Services.
Multidisciplinary child fatality review teams were established with funding from the Flinn
Foundation in some areas of the state, i.e., Maricopa and Pima counties. (These were two-year
grants that expired in 1990.) Additionally, a multidisciplinary child protection team in
Yavapai County began to review deaths of children having current involvement with
Child Protective Services in 1986.
There has not been, however, a coordinated, statewide response to the problem. When Dr.
Michael Durfee addressed the annual Arizona Child Abuse Prevention Conference in 1990,
he heightened awareness of the growing problem of child deaths. His presentation
stimulated Arizona's efforts to follow the lead of other states that had successfully
implemented child fatality review teams and which were making significant strides in
improving reporting, investigation and, ultimately, prevention of child deaths.
Arizona advocates were alarmed by the high rate of child deaths in the state. Experts could
only speculate about the reasons: Arizona's high teen suicide rate? Child drowning?
Homicides? Increasing fatal child abuse? Environmental conditions? The need for action
was urgent.
Unlike other states that focused exclusively on child abuse fatalities, Arizona's advocates
wanted to look at the broader picture and address the reasons for Arizona's unusually high
child death rate. Checking with other states, it was learned that, at that time, several states
were conducting systematic multidisciplinary reviews of child fatalities, and most states had
some form of review broader than the Arizona Department of Economic Security's review
of cases known to Child Protective Services for risk management purposes.
The Governor's Office for Children, with the encouragement of the Arizona Chapter of the
American Academy of Pediatrics and a coalition of nine children's service organizations,
brought the issue to the attention of Arizona House of Representatives members Nancy
Wessel and Debbie McCune Davis. Legislation was prepared and introduced in the 1991
legislative session to create a system of child fatality review for Arizona. The original
organizations included:
Arizona Council for Mothers and Children;
Indian Community Health Services;
Foster Care Review Board;
Court-Appointed Special Advocates (CASA) Program;
Arizona Chapter, American Academy of Pediatrics;
Arizona Chapter, National Association of Social Workers;
Arizona Nurses Association;
Arizona Chapter, National Committee for the Prevention of Child Abuse; and,
Prescott Multidisciplinary Team.
During the hearings in the House, it became apparent that unanswered questions about the -
proposed system and its cost would impede the progress of the bill. The legislation was,
therefore, rewritten to require the establishment of a multidisciplinary, interagency task
force that would develop a plan for the review of all unexplained and unresolved child
fatalities for the purpose of determining and reducing the number of preventable child
The bill required the Governor's Office for Children, serving as lead agency, in cooperation
with the Arizona Department of Economic Security and the Arizona Department of Health
Services, to establish the Interagency Child Fatality Review Task Force. The Task Force was
established to meet at least quarterly to:
Develop a state plan that:
Establishes a systematic review of unexpected child fatalities using
multidisciplinary case consultation teams;
Explores the feasibility and appropriateness of using a single state level case
consultation team or regional teams;
Defines the cases to be reviewed; and,
Analyzes the funding needs and resources for such teams.
Recommend methods of multidisciplinary orientation and training of the case
consultation teams and for those professionals and providers that may be
affected by the results of the child fatality review system.
Specify the data collection necessary to permit identification of demographic
trends and policy issues with respect to unexpected child fatalities.
Submit the report on or before November 15, 1992, to the Governor, the
President of the Senate and the Speaker of the House of Representatives.
This version of the bill passed the House and was successful in the Senate because
supporters continued to confront legislators with the dilemma facing communities and
professionals concerned about the health and welfare of children: Arizona's child death
rates are among the highest in the nation and no one knows why!
By the time the bill (H.B. 2362) became law (Chapter 124) in late September 1991, a work
group had formed. The work group, assembled by the Governor's Office for Children as
lead agency, represented several key interests: the Arizona Department of Economic
Security, the Arizona Department of Health Services, law enforcement, medical examiners,
pediatricians, mental health, American Indians, prosecutors and service providers.
Arrangements were made for a consulting visit from Sarah Kaplan of the American Bar
Association, Center for Children and the Law, Child Maltreatment Fatalities Project. Ms.
Kaplan's services were funded by the Robert Wood Johnson Foundation and the federal
Children's Justice Act. During her three-day visit in September 1991, the consultant met
with members of the work group and made the following observations:
Arizona currently has no statewide procedure for reviewing and responding to
child fatalities;
Arizona currently has no statewide procedure for collecting information about
prior agency involvement with deceased children and their families;
The Arizona Department of Health Services reports of children who die and the
causes of death are based solely on death certificates that have been found in
other states to be incomplete or inaccurate in identifying maltreatment related
A full identification of deaths by abuse and neglect would require additional data
from law enforcement, Child Protective Services and medical examiner records.
These offices do not collect systematic data on child deaths;
There is a lack of communication and cross training among agencies that have a
responsibility for the health and welfare of children. This deficit presents a major
barrier to preventing child fatalities;
There are currently no standard investigation protocols;
There are no pediatric forensic pathologists in Arizona to assist in difficult cases;
Arizona has no standard protocol for child death autopsies;
There are no uniform practices within agencies for notifying other agencies
when there is a possible maltreatment related child death; and,
There is a lack of knowledge at the state level regarding the manner in which the
various tribes respond to child deaths on the reservations.
Ms. Kaplan reported that the individuals whom she interviewed expressed the
overwhelming position that it is time for Arizona to establish a process for the systematic
examination of child fatalities with an emphasis on prevention and improved agency
By mid-October 1991, the Interagency Child Fatality Review Task Force had been assembled.
The Task Force was broadly representative of all the disciplines, agencies and interests on
the local, state and federal levels, including reservations within Arizona. The Task Force
was jointly chaired by the Governor's Office for Children, the Arizona Department of
Economic Security and the Arizona Department of Health Services, and meetings were
facilitated by an outside consultant. The full Task Force met four times: November 1, 1991;
January 3, May 15 and September 11,1992.
The Task Force set forth its mission at the outset. The mission is as follows:
In order to reduce preventable child deaths and promote the well-being of
Arizona's children, the Interagency Child Fatality Review Task Force will
develop a plan that:
1) Addresses the causes of preventable child deaths in Arizona;
2) Identifies an appropriate response to child deaths at the individual
and systems level;
3) Outlines a process for review and recommendation in defined
instances of child death;
4) Outlines a coordinated and comprehensive system for collecting
information about child deaths;
5) Identifies needed changes in public policies; and
6) Makes recommendations for prevention, professional training and
community education.
The Task Force will accomplish this mission through a thorough review of
existing data and systems, through coordination and cooperation from
advocates and agencies involved in the prevention of and response to child
deaths, and with recognition of the diversity of issues and resources
represented throughout Arizona.
Additionally, the Task Force will endeavor to educate the public regarding
the plan, to promote any legislative initiatives needed to realize the plan, and
to champion the implementation of the plan by identifying responsibility for
action and follow-up.
The Task Force outlined the following tasks for the full committee:
Make recommendations regarding the need for state and/or local level teams;
Define the ages of children whose deaths will be reviewed;
Define the types of cases to be reviewed;
* Identify initial resource/funding needs to support the plan;
Identify legislative initiatives needed to support the model recommended in the
Identify efforts needed to champion the adoption of the plan and its
implementation; and,
Review all committee recommendations in light of the varying concerns,
resources and perspectives of Arizona's tribes and other governmental
The Task Force provided strong, committed leadership to the five committees (Child
Fatality Review Teams, Child Fatality Review Protocols, Data, Confidentiality, and
Prevention) which were formed. This guidance has set the course for mandating a system
that will enable Arizona to identify the issues and implement the strategies required to
reduce the number of preventable child fatalities. The committees were responsible for
further defining recommendations consistent with the direction of the Task Force.
The full Task Force charged the committees with the following tasks:
The Data Committee was established to review existing data collection systems,
assess their adequacy, assess possible duplication of effort and define data which
should be collected on an ongoing basis.
The Child Fatality Review Teams Committee was established to make
recommendations to the full committee regarding roles and responsibilities of
state and/or local teams and the composition of the state and/or local teams.
. The Child Fatality Review Protocols Committee was established to review
current responses to child deaths, identify need for protocols for case review and
agency response including channels of communication, and examine
coordination issues with tribes and other jurisdictions.
The Confidentiality Committee was established to identify access to information
and confidentiality issues and make recommendations for addressing these
The Prevention Committee was established to identify training needed for teams
and professionals, and identify community education needs related to
preventable child deaths. The committee also identified successful prevention
programs and collaborative efforts.
Committee chairs met several times in order to ensure consistency and coordination on
overlapping issues. The committee chairs also received consultation from Donald C. Bross,
of the University of Colorado C. Henry Kempe Center for Prevention and Treatment of
Child Abuse and Neglect, and Jane Beveridge, program administrator, Colorado
Department of Social Services.
Additionally, three ad hoc groups convened to address specific issues:
* The medical examiners and other interested parties met to specifically address
how the medical examiners should interface with the proposed child fatality
review teams and other issues specific to their responsibilities when a child dies.
Representatives of American Indian organizations met to gather information
and make recommendations to the Task Force regarding the deaths of American
Indian children on reservations.
0 Members of several committees met to address the impact of Arizona's discovery
laws on issues such as confidentiality and data-sharing among members of the
proposed child fatality review teams.
To gain a baseline, a review was conducted on behalf of the Interagency Child Fatality
Review Task Force of the 981 death certificates for Arizona children (ages birth through 17
years) in 1990. Confirming what other states have found, the overwhelming majority were
children less than three years of age (693 of the 981). Following is a summary of the
preliminary findings regarding manner of death:
Natural Causes
194 cases*
27 cases
41 cases
5 cases
714 cases**
19.8 percent
2.8 percent
4.2 percent
0.5 percent
72.7 percent
* Includes 45 drownings.
**Ninety-five deaths were classified as Sudden Infant Death Syndrome (SIDS).
The review raised many questions among members of the Task Force. How accurate was
the reporting? How many were child abuse and neglect related deaths? Were autopsies
conducted in all cases of unexpected child deaths? It was clear from this preliminary review
that a more complete analysis is needed on an ongoing basis.
In order to reduce the number of preventable child fatalities in Arizona, the Interagency
Child Fatality Review Task Force strongly recommends the following actions:
Adopt a model for the systematic review of all child fatalities in Arizona;
Establish a multiagency, multidisciplinary State Child Fatality Team by January
1994 to identify and address policy issues, and to guide prevention, education and
training efforts based on their findings;
Examine existing protocols and policies of the medical examiner, hospitals and
other medical institutions, law enforcement and social services systems to assess
their adequacy and uniformity in responding to child fatalities. The Task Force
shall make recommendations, where indicated, to federal, state and local
agencies on systems improvement.
Establish multiagency, multidisciplinary local child fatality review teams by
January 1995 to review individual child fatalities, to make recommendations for
improved systems response, and to provide advocacy at the local level;
Adopt or amend legislation to promote the confidential sharing of information
required for comprehensive review and investigation of child abuse and neglect
fatalities among agencies participating in the child fatality review teams;
Provide interdisciplinary professional training and community education which
is developed and implemented in a collaborative manner by all agencies and
organizations involved in and concerned .a bout child fatality prevention and
Develop and implement child injury and death prevention strategies with
leadership from the State Child Fatality Team and local teams, and in
collaboration with agencies, organizations and local community members; and,
Continue the Interagency Child Fatality Review Task Force until the State Team
is fully functioning for purposes of oversight and consultation.
Objective: To establish a State Child Fatality Team (State Team) to review all child deaths in
Purpose: To review and analyze data on all child fatalities occurring in Arizona, identify
trends, and make recommendations to the Governor, governmental agencies and the
Legislature for improving the response to unexpected child deaths and reducing the
incidence of preventable child fatalities in the state.
Review information about all child fatalities occurring in Arizona.
Analyze causes and factors contributing to the deaths of children.
Provide an annual report to the Governor and the Legislature on the incidence,
causes, trends, characteristics and preventability of child fatalities in Arizona.
Examine existing protocols and policies of the medical examiner, hospitals and
other medical institutions, law enforcement and social services systems to assess
their adequacy and uniformity in responding to child fatalities. The Task Force
shall make recommendations, where indicated, to federal, state and local
agencies on systems improvement.
Recommend policy changes and initiatives to prevent child fatalities in Arizona
to the Governor and the Legislature.
Provide case consultation to local review teams in difficult cases.
Encourage and provide guidelines for interagency and interdisciplinary
education, communication, cooperation, coordination and collaboration in child
fatality prevention, identification, response, investigation and prosecution in
Arizona; work with professional organizations to establish training
requirements related to child fatality prevention and intervention.
Establish standards and protocols for local child fatality review teams, review at
least quarterly case review reports from local teams, and provide training and
technical assistance to local teams.
Staffing and Operations: The State Team would meet at least quarterly. Support for the State
Team would be provided by the Arizona Department of Health Services because its public
health mission and resources would be most appropriate given the State Team's focus on
all child deaths. It is anticipated that at least one full-time person with clerical support
would be needed to carry out responsibilities including the following:
* Collect and summarize data in a format prescribed by the State Team;
* Assist the State Team in the analysis of child fatality data;
* Provide staff support for the State Team meetings, including scheduling,
preparing agendas, recording proceedings and following up on
Examine existing protocols and policies of the medical examiner, law
enforcement and social services systems to determine their adequacy and
uniformity, and make recommendations, where indicated, to federal, state and
local agencies on systems improvement;
* Assist the State Team in preparing the annual report to the Governor and
Assist the State Team with interagency and interdisciplinary prevention, ,
education and training efforts;
Assist the State Team in establishing and promulgating standards and protocols
for local child fatality review teams; and,
Coordinate the efforts of the State Team with local child fatality review teams,
e.g., gathering local case review reports, responding to requests for technical
assistance, and facilitating communication.
Composition of the State Team: The State Team would include at least the following
representatives or designees:
County medical examiner (selected by County Medical Examiners);
Pediatrician (selected by the Arizona Chapter of the American Academy of
County Attorney (selected by the Arizona Prosecuting Attorneys Advisory
Arizona Office of the Attorney General;
U.S. Attorney's Office;
Arizona Department of Economic Security - Administration for Children, Youth
and Families;
Arizona Department of Economic Security - Division of Developmental
* Arizona Law Enforcement Officers Advisory Council (ALEOAC);
Arizona Department of Health Services - Office of Women's and Children's
Arizona Department of Health Services - Office of Planning and Health Status
Arizona Department of Health Services - Division of Behavioral Health
Arizona Department of Education;
Administrative Offices of the Courts;
Arizona Department of Youth Treatment and Rehabilitation;
Inter Tribal Council of Arizona;
Indian Health Service;
Navajo Nation;
United States Military Family Advocacy Program;
Arizona Sudden Infant Death Syndrome (SIDS) Alliance; and,
Local child fatality review team member (selected by the State Team).
Subcommittees and/or smaller working groups would be established, as needed, to
efficiently carry out the State Team's responsibilities, e.g., case consultation.
Timeline: The State Team coordinator should be hired by October 1993 with the State Team
appointed by January 1994.
Objective: To establish a statewide system of county-based or regional child fatality review
teams (local teams).
Purpose: To conduct multidisciplinary, multiagency reviews of all unexpected child deaths
in the local area and work together to improve local response with the goal of reducing
preventable child deaths.
Review death certificates of all children (birth to 18 years of age) who have died
in the local area.
Communicate, cooperate, coordinate and collaborate across agencies and
disciplines responsible for the health and welfare of children in order to improve
response and investigation of specific cases of unexpected child deaths in the
local area.
Provide timely access to available information so that child fatalities are
accurately reported and, as appropriate, investigations by authorized agencies are
Collect data in order to determine for the local area the numbers of child deaths,
causes, trends, characteristics and preventability.
Identify, make recommendations and actively work to address systems issues,
including gaps in services, that impact child fatality response at the local level.
Collaborate with the State Team and other local teams in the development of
standards and protocols for child fatality identification, response, investigation
Encourage and provide guidelines for interagency and interdisciplinary
education, communication, cooperation, coordination and collaboration in child
fatality prevention, identification, response, investigation and prosecution in the
local area.
Provide support and advocate for local community education and prevention
efforts to reduce preventable child deaths.
Staffing and Operations: Local teams would be coordinated by a community professional
ideally supported by one of the local agencies involved with child fatalities. The local team
coordinator could be attached to the local county health department, the county attorney's
office, the medical examiner's office or the local Child Protective Services' office. The local
team would elect a chairperson annually. The local team could serve one or more counties,
if necessary or desirable, given the incidence of child fatalities and local resources. Local
teams serving various reservations within Arizona would need to be tailored to the
individual community. In counties with a large number of child fatalities, more than one
team might be needed. Larger teams might also offer support to smaller teams.
Local teams would meet on a regular basis to coordinate prevention and education efforts.
They would meet on an as-needed basis when they are notified of a child death in their area
that meets established criteria for review. The notification would take place as soon as
practical, but no later than 72 hours from the time of death.
The county medical examiner would notify the local team coordinator of all unexpected,
unattended child deaths brought to the attention of the medical examiner's office and
would make copies of findings available to the team on those deaths meeting criteria for
review. Copies of death certificates would be sent by the county health department to the
local team coordinator.
Additionally, local teams would meet at least quarterly to prepare their local report to the
State Team on systems issues and recommendations. Frequency of meetings would be
determined jointly by the local team coordinator and chairperson.
The local team coordinator would be responsible for:
Screening all child death certificates for the local area according to criteria
established by the State Team;
Collecting data regarding the child deaths and reporting these data to the local
Notifying the local team chairperson when a case meets the criteria for local
team review;
Requesting a check of Child Protective Services records through the Arizona
Department of Economic Security CPS Central Registry to identify victims and
alleged perpetrators who are known to Child Protective Services as a result of
prior reports;
Providing support to the local teams, including scheduling meetings, preparing
agendas, recording proceedings and following up on recommendations; and,
0 Reporting results of case reviews to the State Team at least quarterly if there have
been any reviews, and making recommendations to the State Team for systems
Cases to be reviewed by local teams would include all unattended or unexpected deaths of
children under age 18 years of age. This would include, but not necessarily be limited to,
deaths when any of the following are suspected or evident:
Undetermined cause of death as recorded by the county medical examiner;
Head trauma;
Failure to thrive, malnutrition or dehydration;
Suffocation or asphyxia;
Alcohol and other drugs;
Poisoning or ingestion of toxic substances;
Unexplained fractures;
Blunt force traumas;
Homicide, specifically when by neglect or physical abuse;
Suicide or suspected suicide;
Medical neglect;
Sexual abuse;
Gunshot wounds or stabbing;
Sudden Infant Death Syndrome (SIDS); and,
Families known to Child Protective Services in Arizona or elsewhere.
Composition: The local teams would be composed of community members including
representatives of the following, where available:
County attorney;
Pediatrician or family practice physician;
Medical examiner or a designee functioning in this capacity;
Child Protective Services;
County health department;
Domestic violence specialist;
Behavioral health specialist;
Law enforcement; and,
Other family/child advocate.
Additionally, community members having information or expertise relevant in specific
cases would be invited to participate. Examples include:
Juvenile court;
Adult/juvenile probation;
School/preschool/child care specialist; and,
Treating hospital physician/nurse/specialist.
Composition of the local teams serving the various American Indian reservations in
Arizona would need to be individualized to the local community.
Timeline: Local teams should be phased-in beginning in January 1995 or sooner if local
communities prefer.
Objective: To adopvamend legislation to address the issues of access to information and
confidentiality, and thereby allow state and especially local teams to operate in a manner
that promotes the identification and reduction of preventable child deaths.
Issues to be Addressed: The following issues were identified by the Confidentiality
Committee of the Task Force:
Teams must have a mechanism for obtaining information for review;
An individual must be designated to be responsible for gathering information
and assuring that efforts are not duplicated;
The types of records to be accessed must be identified;
Subpoena power must be given to a specific position to assure access to required
County attorneys and law enforcement agencies must be able to withhold
information that might compromise a pending criminal investigation or
Information shared in team meetings must be confidential;
Individual team members must be protected from being compelled to disclose
information shared at team meetings;
0 Individual team members must be able to use the information they have
obtained independently of the team meetings to discharge their own
organizational and professional duties;
Teams must be able to report their activities through the use of non-identifying
information; and,
Team meetings, when individual cases are reviewed, should be exempt from
open meeting laws.
Access to Information Procedures: Upon receipt of a written request from the State or a local
team coordinator, an organization or individual would be required to release the following
materials immediately:
All pertinent information including general medical, hospital, dental and
behavioral health care records of the child, the caregiver and/or relevant others;
All information and records maintained by any state, county or local
government agency including, but not limited to, birth certificates, death
certificates, medical examiner investigative data, parole and probation service
records, social services records, and law enforcement investigative records. The
county attorney, however, may withhold any law enforcement investigative
records which might compromise or interfere with a pending criminal
investigation or prosecution.
The State or local team coordinator should have the right to obtain a subpoena to compel
the production of these documents should they not be produced otherwise.
The State Team would need to give additional attention to access of information from tribal
Confidentiality Procedures: All information and records acquired by the State Team or a
local team would be confidential and could only be disclosed as necessary to carry out the
stated duties of the teams, except that the State or local team coordinator must notify Child
Protective Services of any death that involves reasonable suspicion of neglect or abuse as
required by law.
The external reports of the State Team and local teams would not contain any personally
identifying information. These statistical and descriptive reports would be public records.
No team member, person attending a team meeting, or person presenting information to a
team could testify in any proceeding about the information presented or opinions formed
as a result of participation in a team meeting. Presentation of information to a team would
not preclude the introduction of such information in any proceeding if obtained from
independent sources.
Only the State or a local team coordinator would be permitted to maintain permanent
records presented to the team and records of the proceedings of the team meetings.
Information, documents and records of the teams would not be subject to subpoena or
other discovery.
Meetings of the State and local teams would be closed to the public and not be subject to the
provisions of Arizona Revised Statute § 38-431 et seq. (the Open Meeting Law) when teams
are discussing individual cases of child deaths.
Objective: To conduct at a minimum a review of the death certificates for all children birth
to 18 years of age who die in Arizona.
Under ideal circumstances there would be two levels of review as described above under
State and Local Teams. The first would be conducted by a local team as soon as practical after
the time of death and the second by the State Team (or a designated subcommittee) at its
next regularly scheduled meeting. The local team review would be for the purpose of
identifying situations in which immediate intervention and/or services to the family are
needed. The State Team would id..e.- ntify trends and concerns, and would make
recommendations to reduce preventable child deaths in Arizona.
Data Collection Procedures: The first stage of the review process would involve an
examination of the death certificate. Death certificates would be provided to the local team
by the county health department and to the State Team coordinator by the Arizona
Department of Health Services. While some experts believe that death certificate review
alone is not sufficient to detect child maltreatment fatalities, there is general agreement that
this is an appropriate place to begin the review process. By reviewing death certificates and
following up on missing, unclear or questionable information, the teams can not only gain *
information on child deaths, but can help improve the reliability of the data recorded on
the certificates and the processes which lead to its recording, e.g., investigations.
As circumstances dictate and as resources allow, the local team would conduct a more
comprehensive review on those cases in which circumstances surrounding the death are
questionable, or information is contradictory or missing on the death certificate. Examples
of additional information to be collected might include:
Additional demographic information;
Family profile at time of death;
Classification of death;
Medical examiner's findings;
Public health information;
Child Protective Services or other involvement of the Arizona Department of
Economic Security;
Law enforcement involvement and information; and,
Other information about the suspected perpetrator.
See Appendix B for Data Sets.
The Data Committee of the Task Force conducted a survey of agencies to determine the
availability of information needed for a comprehensive review using the data elements
recommended by the American Bar Association, Child Maltreatment Fatalities Project. The
survey asked whether selected information was currently being collected, the feasibility of
collecting information that was not currently being collected, and whether there were
barriers to sharing information with other agencies. The survey, which was distributed to
150 agencies statewide, indicated that all elements of information needed for a
comprehensive review are being or could be collected, and that there are no major barriers
to sharing information with appropriate agencies. Obtaining information regarding
children who die on reservations and/or children for whom records are in a border
state/country will need further study and coordination. The survey did, however,
underscore that legislation would assist in promoting the sharing of relevant information.
Objective: To develop, review and recommend training for State and local team members,
professional training and community education designed to reduce the number of
preventable child deaths in Arizona
The Prevention Committee of the Task Force discussed the types and nature of professional
training and community education. The Committee has formulated the following
recommendations to be considered by the State Team once it is established:
Existing professional training programs should be identified and catalogued,
with information on training made available to professionals involved in all
levels of child protection efforts, and prevention of and response to child
Training should be developed and provided to assist professionals in identifying
signs of child abuse and neglect, injury prevention and reporting requirements,
and other issues related to the prevention of child fatalities. Professional training
should be targeted at teachers, behavioral health workers, social workers, health
care providers, law enforcement personnel, attorneys, child care workers,
firefighters, emergency medical technicians and others working with child injury
and death. It is also recommended that such training be accepted (or even
required, at the discretion of the professional association) in partial fulfillment of
professional requirements for continuing education credits and certification or
Parenting skills training should be developed and provided for parents,
caregivers, and potential parents, such as high school students, in all areas of the
state, including reservations.
Education should be provided to children and the general public to foster
prevention of child injury and death. This would include support for programs
such as the United Fire Fighters Association's Urban Survival Program, which
utilizes a health and safety curriculum developed by the Association and the
Phoenix Fire Department to instruct elementary and junior high school
students. The program is a collaborative effort of teachers, firefighters, parents,
local hospitals and local educational communities.
When planning professional training and community awareness activities, there
should be communication, coordination, cooperarion and collaboration among
the many agencies and organizations with a role in the prevention of child
injury and death. Additionally, there should be multidisciplinary training
conferences with representation from all categories of professionals involved
with child fatality prevention and intervention. These conferences should be
integrated where appropriate with existing conferences that address child fatality.
The media should be involved in planning and implementing community
awareness campaigns directed toward the prevention of child injury and death.
The effectiveness of such a collaborative effort between the media and
community agencies has been amply demonstrated in the area of drowning
prevention in Arizona.
Objective: To evaluate programs designed to prevent child injury and death and, based on
proven results, disseminate this information to and through the many agencies and
organizations concerned with the prevention of child injury and death.
Many agencies and organizations fund programs and activities designed to prevent child
injury and death. The State Team can play an important role in cataloguing these efforts
and, furthermore, can provide leadership in the design and dissemination of evaluation
results. People need to know what works and why, so that effective programs can be
replicated and resources focused on strategies which have been proven effective.
Objective: To foster community mobilization efforts in order to prevent child fatalities.
Because prevention is everyone's business, the State Team and local teams should
encourage local community members to foster closer ties with neighbors and to "look out
for each other."
Community mobilization efforts should be a key to prevention efforts at the local level.
Grassroots efforts are an effective way to disseminate information and launch action.
Community centers, local neighborhood associations, schools, family resource centers and
other places where people gather to share information should be regarded as potential sites
for local initiatives to prevent child injury and death.
Support is needed for communities' efforts to develop their local resources. This support
could include developing sites for the location of intergenerational services, including a
home base for the local team to meet. ~ublic/~rivaptear tnerships would be needed to make
the development of such family support centers a reality.
Community mobilization flirts should be a key to prevention efforts
at the local level.
For example, the Pima County Health Department's public health nursing division, in
collaboration with the United Way of Tucson, has established the Grandparents Adopted
for Parental Support or GAPS program. The GAPS program utilizes volunteers in early
intervention to prevent child abuse.
Objective: To foster communication, coordination, cooperation and collaboration among
agencies, organizations and individuals involved in and committed to the health and
welfare of Arizona's children.
There must be a sincere commitment among all agencies, organizations and individuals
concerned with child health and welfare to work together as partners in preventing child
injury and death. This should include sharing information, jointly developing and
supporting programs with proven effectiveness, and establishing and promoting policies
and practices that foster a unified and comprehensive approach to prevention.
The following expenses would be required to support the State Team for the first year.
Coordinator (1 FTE, Grade 20) $35,750
Clerical (.5 FI'E, Grade 11) 9,260
Equipment (including computer)
Travel (in and out-of-state)
Indirect 4,500
Operating Expenses (including printing) 10,000
State Team Meeting Expense 5,000
It is recommended that the State Team be funded for the first year (Fiscal Year 1993-94) by
legislative appropriation. It is further recommended that a fund be established in the State
Treasurer's Office utilizing resources obtained by adding $2 to the existing price ($6) of an
Arizona death certificate. (In Fiscal Year 1990-91, there were approximately 55,000 death
certificates issued.) This fund would be utilized to fund the State Team in subsequent years.
Funding for local child fatality review teams would be explored by the State Team. Possible
sources include sharing coordination costs with existing child abuse multidisciplinary
teams, use of Children's Justice Act grant funds, or rotating responsibility for providing
meeting rooms, notification and information gathering responsibility. In most cases, child
fatality reviews may not impose additional duties but be a different way to perform the
existing responsibilities of the professionals involved with the unexpected death of a child,
for example, medical examiner, Child Protective Services, law enforcement and
1. National Center for Prosecution of Child Abuse, Update, Volume 5, Number 7, July 1992. -
2. Kaplan, S. R., Child Fatality Legislation in the United States, American Bar Association,
Center for Children and Law, 1991.
3. The Annie E. Casey Foundation and the'center for the Study of Social Policy, Kids Count Data
Book: State Profiles of Child Well-Being, 1992, p. 140.
4. Ibid., p. 140.
5. Arizona Department of Health Services, Office of Planning and Health Status Monitoring,
Unintentional Drowning Deaths, Arizona 1990, April 1992.
6. Oregon Department of Human Resources, Child Fatality Review Process: A "How-To" Manual,
p. c-1.
7. Kids Count Data Book, op.cit., p. 27.
8. Arizona Department of Health Services, Office of Planning and Health Status Monitoring,
Arizona Health and Vital Statistics 1990, March 1992.
9. National Committee for Prevention of Child Abuse, 1991 Annual Fifty-State Survey Results,
1992, p. 12. (The report states that these data are based on the reports of 36 of the 50 states
10. National Center for Health Statistics, "Advance Report of Final Mortality Statistics, 1988,"
Monthly Vital Statistics Report, Volume 39, Number 7, pp. 1-12, as reported in National
Committee for Prevention of Child Abuse, 1991 Annual Fifty-State Survey Results, p. 12.
11. Kreck,C., 'Shaken Baby Syndrome," The Denver Post, August 7,1991.
12. Jason, J., "Centers for Disease Control and the Epidemiology of Violence," Child Abuse and
Neglect, Volume 8, 1984, pp. 279-283, in Schloesser, P.; Pierpoint, J.; and Poertner, J., "Active
Surveillance of Child Abuse Fatalities," Child Abuse and Neglect, Volume 16,1992, p. 3.
13. "Active Surveillance of Child Abuse Fatalities," op.cit., p. 5.
14. Lundstrom, M. and Sharpe, R., "Getting Away with Murder," Public Welfare, Summer 1991, p.
15. Kids Count Data Book, op.cit., p. 13.
16. Ibid., p. 27.
17. "Getting Away with Murder," op.cit.
18. Durfee, M.; Gellert, G.; and Tilton-Durfee, D., "Origins and Clinical Relevance of Child Death
Review Teams," The Journal of the American Medical Association, Volume 267, Number 23, June
17,1992, p. 3172.
19. Durfee, M., Los Angeles Department of Health Services, Memo to Liaisons for Child Death
Review, June 17,1992.
Appendix A
a Interagency Child Fatality Review Task Force a Members
State Agencies
Marsha Porter, Co-Chair
ACYF Program Administrator
Department of Economic Security
Janice H. Piepergerdes
Department of Youth Treatment and
Susan Burke, Co-Chair Bette Denlinger
MCH Child Health Section Manager School Health Specialist
Department of Health Services Department of Education
Phoenix Phoenix
Bev Ogden, Coordinator
Assistant 'Director
Governor's Office For Children
Steven L. McMurtry, Ph.D.
Foster Care Review Board
Assistant Professor
Arizona State University
Diane Renne
Executive Director Juman Abujbara
Interagency Coordinating Council for Infants and Office of the ldedical Director
Toddlers Arizona Health Care Cost Containment System
Phoenix Phoenix
Benidia A. Rice, J.D.
Office of the Attorney General
Rhoda Cosmano
Quality Assurance Specialist
Arizona Department of Economic Security
Robert Schackner, M.A.
Community Program Representative
Department of Health Services
Edward B. Truman, J.D.
Office of the Attorney General
Virginia Richter, J.D.
Office of the Attorney General
Kay Ekstrom
Committee on Juvenile Courts
William N. Marshall, Jr., M.D.
University of Arizona
College of Medicine
Joanne C. Gersten, Ph.D., Manager
Arizona Department of Health Services
The Honorable Nancy Wessel, Chair
Health Committee
Arizona House of Representatives
The Honorable Chris Cummiskey
House of Representatives
Community Organizations
Mary Ellen Rimsza, M.D., President
Arizona Chapter, American Academy of
Daniel B. Kessler, M.D., F.A.A.P
Director, Developmental & Behavioral
Children's Health Center
St. Joseph's Hospital
Hilda L. Simo, Program Director
Chicanos Por La Causa, Inc.
Marlene Kaatz. Director of Client Services
Mental ~ealth.~ssociatioofn Maricopa County
Dana Dapper
Children's Services Coordinator
Southeastern Arizona Behavioral Health
Captain Me1 Risch, Business Manager Nogales
~ & o n aL aw Enforcement 0fficer'~~dvisory
Council Morlene Cooper Wells, M.S.W.
Phoenix East Valley Behavioral Health Association
Trula Breuninger, Executive Director
Indian Community Health Services
Paul Bakerman, M.D.
Pediatric Critical Care
Phoenix Children's Hospital
Rebecca Ruffner Tyler, Coordinator
Prescott Multidisciplinary Team
Irene Jacobs, M.S.W.
Children's Action Alliance
Dorothy A. Hanson, R.N., B.S., M.A. Shirley Wagner
Arizona Council of Mothers and Children Arizona Chapter of SIDS Alliance
Good Samaritan Re-p jonal Medical Center Mesa
Federal and Local Government Agencies
Dorothy J. Meyer, C.N.M., M.P.H.
Maternal and Child Health Consultant
Indian Health Service
Ella Y. Shirley, M.S.W.
The Navajo Nation
Division of Social Services
Window Rock
Mike Goimarac, J.D.
Deputy County Attorney
Apache County
St. Johns
Dyanne Greer, J.D.
Deputy County Attorney
Maricopa County
Aleene Hughes Heinz Karnitschnig, M.D.
Social Worker Consultant
United States Department of the Interior Forensic Pathologist
Bureau of Indian Affairs Paradise Valley
Sherrilla McKinley
Salt River Pima-Maricopa Indian Community
Sco ttsdale
Henry Montano
United States Air Force
Family Advocacy Program
Kathy Paleski, Detective
Office of the Coconino County Sheriff
Philip E. Keen, M.D.
Maricopa County Medical Examiner
Bruce 0. Parks, M.D.
Chief Medical Examiner
Pima County
Derrick Johnson
United Phoenix Firefighter Assoc. Local 493
Mary Ella Cowan, Detective Chuck Teegarden
Office of the Cochise County Sheriff Executive Director
Bisbee Pinal County Cities in Schools
Lt. Sherry Kiyler
Phoenix Police Department
General Investigations/Homicide
Appendix B
Data Sets
Name, AKA
Date of birth
Date of death
Address at time of death
Race, ethnicity
Time of death
Place of death
Category of
- motor vehicle related, including pedestrian
~njuries- non-motor vehicle related
Natural Causes
0 Undetermined
Medical Examiner Information
Cause of death
Manner of death
Name of certifying physician, attending physician, medical
examiner or tribal law enforcement authority
Family Profile at Time of Death
Primary /secondary caretakers
Marital status of parents
Other family members, significant others
Primary caretaker impairments (drug, alcohol, illness, etc.)
Family income, source, employment
Caretaker's educational level
Number of people in home
Condition of home
Health System
Health history
Insurance coverage
Child Protective Services
Open CPS case at death
History of CPS involvement with family (Arizona or elsewhere)
Foster care placements
Juvenile Court involvement/child's criminal history
Prior or current law enforcement involvement due to abuse/
Did child die in foster care?
Law Enforcement
Investigation completed
Arrest made or pending
Case referred to county attorney
Suspected Perpetrator(s) (If CPS or Law Enforcement)
Date of birth, age
Race, ethnicity
Criminal record
Weapon involved
Substance abuse
Child maltreatment history
History of violence
History of mental illness
Appendix C
Article by Dr. Michael Durfee
Special Communication
Origins and Clinical Relevance
of Child Death Review Teams
Michael J. Durfee, MD; George A. Gellert, MD, MPH, MPA; Deanne Tilton-Durfee
Interagency child death review teams have emerged in response to the
increasing awareness of severe violence against children in the United States.
Since 1978, when the first team originated in Los Angeles, Calif, child death re-view
teams have been established across the nation. Approximately 100 mil-lion
Americans or 40% of the nation's population now live in counties or states
served by such teams; most have been formed since 1988. Multiagency child
death review involves a systematic, multidisciplinary, and multiagency process
to coordinate and integrate data and resources from coroners, law enforcement,
courts, child protective services, and health care providers. This article provides
an introduction to the unique factors and magnitude of suspicious child deaths,
and to the concept and process of interagency child death review. Future ex-pansion
of this process should lead to more effective multiagency case man-agement
and prevention of future deaths and serious injuries to children from
child abuse and neglect.
OVER 1000 American children die each
year of intentional injuries at the hands
of a caretaker (P. W. McClain, MS, J. J.
Sacks, MD, MPH, R. D. Froehlke, MD,
A. D. Ewigman, MD, oral communica-tion,
April 1992).' Most are infants or
young toddler^.^"' No single health, so-cial
service, law enforcement, or judicial
system exists to track and comprehen-sively
assess the circumstances of child
death^.^ This article describes the ex-panding
national implementation of in-teragency
multidisciplinary child death
review teams in response to the critical
need for systematic evaluation and case
management of suspicious child deaths.
From the Los Angeles (Calif) County Department of
Health Services (Dr Durfee). Orange County Health
Care Aoencv. Santa Ana. Calif (Dr Gellerl), and Los
Angel& ~odnty(C alif) interagency council on Child
Abuse and Neglect (Ms Tiltoil-Durfee).
Reprint requests to Department of Health Services.
County of Los Angeles. 313 N Figueroa St, Los Ange-les,
CA 90012 (Dr Durfee).
It is difficult to estimate the incidence
of fatal child abuse using traditional data
systems! Available statistics reflect var-ied
levels of competence in detection,
evaluation, and recording of child deaths
and variation in definitions used by dif-ferent
agencies. The National Commit-tee
for Prevention of Child Abuse, which
annually surveys all states, reported a
national incidence of 1383 child abuse
fatalities for 1991.' The National Com-mittee
for Prevention of Child Abuse
survey does not utilize a rigorous case
definition and excludes cases not known
to social service departments or other
child abuse agencies. The Centers for
Disease Control uses vital statistics and
Federal Bureau of Investigation Uni-form
Crime Reports to arrive at an an-nual
national figure of about 2000 child
fatalities from abuse or neglect (P. W.
McClain, MS, J. J. Sacks, MD, MPH, R.
D. Froehllte, MD, A. D. Ewigman, MD,
oral communication, April 1992). In Los
Angeles County, California, 14 years of
multiagency child death review suggests
that the numbers will increase as abuse-related
fatalities are more accurately
identified and reported.
Death scene investigators evaluating
adult victims may follow protocols fairly
objectively. First responders to an im-minent
or actual child death scene, how-ever,
may be swept up in an intense
focus on providing life support for the
victim and emotional support for the
victim's family. Even when it becomes
apparent at the hospital that the cir-cumstances
of death are sus~iciousd. e-lays
may occur before an investi&tor
returns to the scene of the event, or
investigators may visit only the hospital
and request that the medical staff in-terpret
the death.
Criminal investigation of a child death
caused by a caretaker is unique for in-vestigators,
since the perpetrator is le-gally
responsible for the child and has
continuous access to the victim. This
contrasts with the majority of adult ho-micides
where the victim and perpetra-tor
are not cohabiting at the time the
injury causing death is perpetrated.
Child deaths may also result from the
neglect of children by caretakers who
are expected to provide for the child
victim's biological needs. The concept of
not feeding, protecting, or otherwise pro-viding
for the unique needs of a young
child may be difficult to comprehend for
a homicide detective with no child abuse
Most suspicious child deaths occur
among very young children. Studies of
"fatal child abuse" or of "homicide by
3172 JAMA, June 17, 1992-Vo1267, No. 23
nfsd frm JAMA @ Tim Journsl ol fhe American Medicd Assoa
J W 17. 1992 V d w 267
Copyrlghl 1992. AAmerioln Medical Assorie~tion
Child Death Review Teams-Durfee et al
Table 1.-Evolution of Child Death Review Teams in the United States* CHILD DEATH REVIEW TEAMS
Status of Present Population
First Team Statust Covered by
I I - Teams, in
State Year Location State Local Millions
California 1978 Los Angeles County x x 29.8
South Carolina 1985 State x 3.5
Missouri 1986 Boone Countv x x 5 1
Oregon 1986 State x x 2.8
Minnesota 1987 State x x 4 4
Ohio 1988 Frankl~n County x 1 .O
Colorado 1988 State x x 3 3
Florida 1989 Locallstate x x 12.9
Illinois 1989 Cook County x 5.6
Vermont 1989 State x 0.6
Georgia 1990 State/local x x 6.5
Iowa 1990 State x 2.8
Indiana 1991 Marion Countv x 10
Maryland 1991 State x 4.8
New Hampshire 1991 State x 1.1
New Mex~co 1991 State x 15
North Carolina 1991 State/local x x 6 6
Washmaton 1991 Sookane Countv x x 4 9
Hawaii 1992 Honolulu County x 0.8
Maine 1992 State x 1.2
Oklahoma 1992 State x 3 I
Total 103
*States having state andlor local teams including (1) interagency teams including health, human and social
services, and criminal justice representatives; (2) inclusive intake of potentially suspicious child deaths from coroners'
or health databases, or from local referral; and (3) team review of cases.
tStatus as of April 1992.
caretaker" indicate that 50% of the vic-tims
are under 1 year of age.24 These
young victims may have no previous
records or only medical records that are
not frequently accessed as part of the
death investigation. Autopsies of young
children require a specialized under-standing
of pediatrics, pathology, child
abuse, and forensic investigation. Few
jurisdictions have such experts. Autop-sies
may be conducted by physicians with
no formal pathology training, much less
specialization in forensic pathology.? Ra-diological
and laboratory equipment for
clinical or forensic tests may make a
diagnosis possible?%ut these tests may
be unavailable locally or may not be or-dered
to reduce costs.
The above factors contribute to inap-propriate
surveillance, potential under-reporting,
misclassification, and misman-agement
of child deaths. Case manage-ment
is further confounded by problems
in interagency communications. An ex-treme
example of a case lost in multiple
systems involved a 10-month-old infant
whose family had 52 agency contacts
before the child was eventually beaten
to death. Contacts included law enforce-ment,
child protective services, hospital
emergency departments, public health
nurses, and a psychiatric emergency
team. Most individual agency actions ap-peared
reasonable, but no single agency
had a comprehensive and collective
record of contacts with the family.
JAMA. June 17, 1992-Vol267, No. 23
Child abuse prevention and interven-tion
are relatively new phenomena.
"Child abuse" was not indexed in Index
Medicz~us ntil 1965a nd "infanticide" was
not indexed until 1970. RIuch of the lim-ited
medical literature on fatal child
abuse has been published within the last
3 years. The preponderance of medical
and other data are available only from
uncirculated source^.^^^^
Los Angeles County began the na-tion's
first interagency child death re-view
team involving criminal justice and
health and human service professionals
in 1978. This team evolved from the ex-perience
of clinical teams conducting
"death review" rounds on internal med-icine
wards. Weekly review of all adult
deaths on a busy hospital service dem-onstrated
the educational benefits of a
systematic review of death as a way to
improve services to the living. Child
death review adapted the process of re-view
to the premature deaths of chil-dren
in the community. By April 1992,
interagency, multidisciplinary child
death review teams drawing cases sys-tematically
from agency referrals, cor-oner-
medical examiner records, or vital
statistics had been established at the
state and/or local level in 21 states (Ta-ble
l), covering 100 million Americans
or 40% of the nation's population.
Multiagency child death review teams
lend greater clarity and coherence to
case management and help define intra-agency
and interagency problems. The
core team includes at least five members
with representatives from the coroner-medical
examiner's office, law enforce-ment
agencies, prosecuting attorneys
(municipal, district, or state), child pro-tective
services, pediatricians with child
abuse expertise, and health profession-als,
including public health nurses.13-l5
In most states, the coroner-medical
examiner or health department supplies
a list of child death cases selected
through an established protocol designed
to include all deaths with suspicious cau-sation.
Colorado and Missouri state
teams and some local teams review all
child deaths from any cau~e.'~CJ~on fi-dentiality
of medical records is main-tained
within the team process. The med-ical
examiner or other medical profes-sionals
interpret autopsy findings and
medical history for nonmedical team
members. Law enforcement assumes the
role of case manager if criminal inves-tigation
is warranted. Prosecutors ed-ucate
the team on criminal law pertain-ing
to individual cases and pursue liti-gation
as appropriate. Child protective
services provides records from previ-ous
contacts with the victim'sfamily and
coordinates efforts to protect surviving
siblings. Medical professionals access and
interpret clinical records of trauma or
physical neglect, educate the team on
pertinent medical issues, and may assist
in referrals for direct health care eval-uation
and services for surviving family
members. Public health specialists may
provide vital records and can develop
epidemiological risk profiles of families
for early detection and prevention of
child death and serious injury.
Other team members can include rep-resentatives
from mental health agen-cies,
fire department emergency medi-cal
personnel, probation and parole de-partment~,
s'u~b stance abuse treatment
providers, local school and preschool ed-ucators,
sudden infant death syndrome
experts, and state or local child advo-cates.
Private hospitals may participate
if they are actively involved with child
abuse prevention or have involvement
in a case under re vie^.'^.'^
Most team members are employed at
the direct service level, although senior
managers and political appointees may
be a part of some mandated state teams.
Most teams have grown in the number
and diversity of members during the
first year of reviewing cases.
Teams may function at the state and/
or local jurisdictional level. Some large
Child Death Review Teams-Durfee et al 3173
Table 2.-Potential Outcomes/lrnpact of Inter-agency
Child Death Review
lmprovement of the following:
(I) lnteragency communication for management of
death cases and for management of future nonfa-tal
(2) Accuracy of and capability for criminal, civil, and
social intervention for families with fatalities.
(3) Intervention wtth surviving and at-risk siblings, in-cluding
counseling and follow-up.
(4) Profile of families at risk for fatal or severe abuse
and neglect.
(51 lnlraagency and interagency systems uslng cases
to aud~tth e total health and social servlce systems
and to minimize misclassification of cause of child
(6) Evaluation of the impact of specific risk factors, in-cluding
substance abuse, domestic violence, and
previous child abuse.
(7) lnteragency services to high-risk families.
(8) Data collection for surveillance of deaths and for
study of categories of death such as bathtub
drownings or burns.
(9) Relationship with mass media and use of media to
educate the public about child abuse prevention.
(1 0) Intercounty and interstate communications regard-ina
child death.
states have local teams but no state
teams. The trend is toward establishing
both local and state teams (Table 1). Mis-souri
became the first state to establish
a complete functioning network of state
and local teams in all jurisdictions (March
1992). The various teams began through
individual initiative, state-initiated leg-islation,
or administrative mandate.
Some county teams gather in regional
clusters and the southern states sched-uled
the first regional multistate meet-ingin
South Carolina in April 1992. Most
teams function with little or no specific
funding; resources for team management
come from the member agencies. A few
teams receive additional funding for staff
support. All teams save costs through
increased effectiveness of interventions
and reduced duplication of efforts.
Table 2 summarizes several of the po-tential
outcomes of multiagency child
death review. Few data are currently
available but should become more so in
the next few years. One of the first tan-gible
changes in case outcome in Los
Angeles County occurred in 1983. Seven
child death cases chosen from a system-atic
team review from 1981 through 1983
that were designated as natural or ac-cidental
in causation were modified at a
coroner's inquest to "death at the hands
of another." Several of these cases re-sulted
in criminal actions and referrals
of surviving siblings for protective ser-vices.
Another case reviewed by the
team was reclassified from homicide to
natural death.
The multiagency team process is more
vigorous than the single agency process,
more capable of clear!y identifying acase
that is suspicious, and more able to deal
with special challenges, such as the dif-ficulty
of identifying the perpetrator out
of multiple caretakers, separating out
3174 JAMA. June 17, 1992-Vo1267, No. 23
physical findings that confuse the de-termination
of cause of death,17 or dis-tinguishing
sudden infant death syn-drome
from suffocation.'Vhe results
are more focused, more complete, and
the process is more accountable. Out-come
reports from the team add to that
Child death review also creates an
opportunity for a systematic review of
agency actions (and inactions). This has
been particularly important with respect
to improving and integrating intera-gency
communications, and allowing
agencies the opportunity to address def-icits
in their own systems. Surviving
siblings can be identified and referred
for protection, evaluation, and service.
Health professionals with previous con-tacts
with the child or family can im-prove
their clinical judgment and case
management skills by learning retro-spectively
from the follow-up informa-tion
obtained through child death re-view.
Small case numbers in rural counties
and the ability of the involved agencies
to focus extensively on each case offers
an opportunity for some teams to de-velop
specifically targeted local preven-tive
actions for childhood injury. Such
action may involve various multiagency
prevention programs, including child
safety seats for automobiles, drowning
prevention, and suicide prevention.
Law enforcement, child protective ser-vices,
coroner's investigators, and pub-lic
health nursing team members all con-duct
home visits and investigations.
These professionals thereby possess out-reach
capability for families that are be-yond
the coverage of mainstream com-munity
medical systems. Team educa-tion
allows such professionals to become
a resource for detecting and referring
medical and social problems that pre-dispose
a family to violence. High-risk
problems that may be detected include
pregnancies involving maternal sub-stance
abuse, pregnant women exposed
to domestic violence, failure-to-thrive
infants, and homes lacking basic child
safety measures.
Other special populations could ben-efit
from review, including spousal ho-micides
with surviving children, child
siblings as perpetrators, children killing
parents, and homicides of disabled adults
and the dependent elderly by family
members. The team process may be
extended to live children with the ad-dition
of children with severe nonfatal
Child and adolescent suicides with a
history of prior child abuse represents
another potential population for multi-agency
review and management. In Los
Angeles County, 28% of all suicides un-der
the age of 18 years in 1989 (n=43)
were found to have a history of previous
child protective services. The incidence
of previous child abuse was inversely
related to age (85% of 14-year-old~).~
This has resulted in the formation of a
multiagency task force to address child
and adolescent suicide.
The Los Angeles County coroner in-vestigates
approximately 40 fetal deaths
annually from a countywide total of
over 1000 fetal deaths per year. Most of
the coroner's cases appear to result from
maternal substance abuse, usually co-caine.
Several fetal deaths each year
result from homicide or assault of a
pregnant w0man.l Fetal deaths tradi-tionally
receive intervention only at the
hospital. Team intervention with fetal
deaths from maternal substance abuse
may include a public health nurse re-ferral
to help the mother and other fam-ily
members prevent such behavior in
the future. Fetal deaths from assaults
on the mother may be followed by crim-inal
justice investigation and prosecu-tion.
The child death review team is an
activity with significant impact on basic
health care. Phvsicians and other health
professionals iontribute to and benefit
from the child death review team pro-cess.
Physicians assure that medical
records are made available to review
teams, explain and interpret medical
findings for nonmedical team members,
and assist with case referral and man-agement.
Participating clinicians may
improve their access to other agencies
and thereby achieve a broader base for
health care service provision to children,
and increase their sensitivity for man-agement
of high-risk families.
Medical team members are exposed
to extensive clinical material, including
Munchausen syndrome by p r o ~ y , ' ~ ~ ~ s u d -
den infant death syndrome, apnea and
suffocati~n,'d~r owning:' burns,22 ne-g
l e ~ t ,a~bd~om inal trauma,24 neonati-tide,%
shaken baby syndr0me,2~?l and
head trauma.% Clinical pathological con-ferences,
even for unvsual presentations,
may include child abuse in the differen-tial
Medical team members have special
value as liaisons with other health care
providers who cared for the child before
the incident that caused death. Occa-sionally,
previous caretakers will have
noted injuries or family problems that
may assist in defining a pattern of abu-sive
behavior. Previous caretakers may
also have failed to report suspected child
Child Death Review Teams-Durfee et al
abuse or neglect and may benefit from
peer support and consultation.
The US Advisory Board on Child
Abuse and Neglect has made specific
recominendations to the Secretary of
Health and Human Services about the
development of child death review
teams" and held a national hearing on
fatal child abuse in Los Angeles in April
of 1992. The US Department of Health
and Human Services is heading an in-teragency
task force to address imple-mentation
of this process nationally. The
US Public Health Service objectives for
the year 2000 include recommendations
1. Daro D, McCurdy K. Curreltt Trends iii Child
Abuse Reporting and Fatalities: The Resl~ltsof the
1991 A?lnual I;f?y State Snn!ey. Chicago, Ill: Na-tional
Committee for the Prevention of Child Abuse;
2. Christoffel K. Violent death and injury in US
children and adolescents. AJDC. 1990;144:697-706.
3. Division of Injury Control, Center for Environ-mental
Health and Injury Control, Centers for Dis-ease
Control. Childhood injuries in the United
States. AJDC. 1990;144:627-F46.
4. Los Angeles County Interagency Council on
Child Abuse and Neglect. Child Death Revim Team
Report. Los Ar~geles, Calif: Los Angeles County
Interagency Council on Child Abuse and Neglect;
1990, 1991.
5. Durfee M. Fatal child abuse: intervention and
prevention. Protecting Child. Spring 19839-12.
fi. AndersoriTL, Wells ,ST. Data Collection for Child
Ebtalities: Existing Efforts and Proposed Guide-li?
l,~sW. ashington, DC: American Bar Association
Center on Children and the Law and the American
Academy of Pediatrics; 1992.
7. Lundstrom M, Sharpe R. Getting away with
murder. Public Welj?are. Summer 1991:18-29.
8. Meinman PK, Blackbourne SD, Marlcs SC, Karel-las
A, Belanger PL. Radiological contributions to
the investigation and prosecution of eases of fatal
infant abuse. N Engl J Med. 1989;320:507-511.
9. Riffenbnrgh RS, Lakshmanan S. The eyes of
child abuse victims: autopsy findings. J Forensic
Sci. 1991;36,:741-747.
10. Smith P, Durfee M. Child Death Review: A
Review of Unpublished Reports by Stutes. Los An-geles,
Calif: Los Angeles County Dept of Health
for state-level child death review teams
in 45 states.31 The task for the 1990s will
be to build a national network of teams
and to integrate that network with
health care providers to establish a pre-vention
system for families and children
before they are injured or killed.
Child death review began initially as a
method to address suspected child abuse
or neglect fatalities. Many teams have
expanded this focus to address all coro-ners'
cases including suicide, accidental
deaths, and natural deaths. Prevention
of child abuse fatalities involves early
detection of families at risk and coordi-nated
lnultiagency intervention directed
at those risk factors. Factors that ele-vate
risk in a particular locality can be
Services; 1991.
11. A Report of Oregon Fatalities due toAb7~saa nd
Neglect, 1985-89. Salem, Ore: State of Oregon, Dept
of Human Resources, Child Protective Services
Program; 1990.
12. Colorado Child Fatality Review Coinm,iltee AIL-nl~
aRl eport and Conference Proceedings. Denver,
Colo: Colorado Child Fatality Review Committee;
13. Cal$om~ia Protocol for Child Death Review
Teams. Sacramento, Calif: California Dept of Jus-tice;
14. Grauik LA, Durfee M, Wells ST. Child Death
Review Tea?~sA: Manual for Design a?& Imple-mentation.
Washington, DC: American Bar Asso-ciation
and the American Academy of Pediatrics;
15. Kaplan SR, Granik LA. Child Fatalities k-vestigative
Proredltres Mannal. Washington, DC:
American Bar Association and the Anierican Acad-emy
of Pediatrics; 1992.
16. Strangler GJ, Kivlahan C, Knipp M. How can
we tell when a child dies from abuse? Missouri's
new law will help answer that question. Public
I4'e'elfare. Fall 1991;5-11.
17. Levin AW. Ocular manifestations of child abuse.
Opl~thalnzolC lir~N ovth Am. 1990;3:249-262.
18. Meadows R. Suffocation, recurrent apnea, and
sudden infant death. J Pediatr. 1990;117:351-357.
19. Sullivan CA, Francis GL, Bain MW, Hartz J.
Munchausen syndrome by proxy: 1990 a portent for
problems? Clin Pediatr. 1990;29:587-590.
20. Kravitz RM, Wilnott RW. Munclrausen syn-drome
by proxy presenting as factitious apnea. Cli7z
Pediatr. 1990;29:687-590.
identified through the study of past child
deaths. The team process facilitates more
competent and predictable intervention
through agencies that have learned to
work together more effectively.
The interagency child death review
team is clearly an idea whose time has
come. Child death review teams have
grown rapidly in the last 3 years with
little or no external funding and limited
national leadership. Federal and state
funding and support of child death re-view
teams would greatly facilitate the
expansion of review across the nation.
A national data registry could quantify
and demonstrate the impact on detec-tion,
management, and prevention of fa-tal
child abuse on an ongoing basis.
21. Griest IW, Ztimwalt RE. Child abuse by tlrown-ing.
I'ediatrics. 198)11!1;8:k41-46.
22. McLoughlin E, McGuire A. The causes, cost,
and prevention of chiltlhood burn injuries. A.JDC.
23. Margolin I,. Fatal child neglect. CI~ildW elfa.re.
24. Fossum RM, Descheneaux KA. Blunt trauma
of the abdomen in children. J Forensic Sci. 1991;
25. Saunders E: Neonaticides following 'secret'
pregnancies: seven casr: reports. Public Health Rep.
26. Alexander R, Sato Y, Smith W, Rennet T. In-cidence
of impact trauma with cranial injuries as-cribed
to shaking. AJDC. 1990;144:724-726.
27. Spaide RF, Surengel RM, Scharre DW, Mein C.
Shaken baby syndrome. Am Fanz Pliysician. 1990;
28. Apolo JU. Bloody cerebrospinal fluid: traumatic
tap or child abuse? Pcdiatr Emerg Care. 1987;2:
29. Reece RM. Unusual manifestations of child
abuse. Pediatr Clin North Am. 1990;37:905-921.
30. US Advisory Board on Child Abuse and Ne-glect.
Creating Can'?l,g Co?nnzun,ities: Blueprint for
an Eflective Federal Policy on Child Abme and
Neglect. Washington, DC: US Advisory Board on
Child Abuse and Neglect; 1991.
31. Healthy People 2000: National Healtlt Promo-tion
and Disease Prevention Objectizies. Washing-ton,
DC: US Dept of Health and Human Services,
Public Health Service; 1990.
JAMA, June 17, 1992-Vol 267, No. 23 Child Death Review Tearns--Durfee et al 3175
. Printed and Published in the United States of America
Click tabs to swap between content that is broken into logical sections.