Teri Covington "Child Death Review Teams" - Part 2- NDPA Symposium 2012
All Drownings and Layer of Protection Breached Categories are not mutually exclusive700 664600500400 347300200 128100 74 63 79 29 12 29 12 18 18 0
Child Used Drugs or Alcohol Leading up to Drowning n-=712 Ages 15 - Over 18 Ages 10-14 18 Years OldYes Count 8 48 10 % 3% 12% 45%No Count 161 186 6 % 53% 48% 27%N/A Count 40 16 0 % 13% 4% 0%UK Count 95 136 6 % 31% 35% 27%Total Count 304 386 22 % 100% 100% 100%
Drowning Deaths by Manner N=2,440 Suicide 0% Homicide 4% Accident 92% Undetermined 2% UK Pending 1% 1% Natural 0%
Did an Act of Omission or Commission Cause or Contribute to the Death N=2,440 Under Ages Ages Ages Ages age 1 1 - 4 5 - 9 10-14 15-18 No 25% Yes/Probable 78% 67% 57% 35% 26%Yes/Pro- bable 56% No 9% 18% 20% 41% 47% UK 19% 13% 15% 23% 24% 27% Unknown 100% 100% 100% 100% 100% Total
Type of Act N= 1,355 Categories are not mutually exclusive800 690700 Caused600 Contributed500400 303300200100 81 73 68 56 43 26 26 14 2 0 6 1 0 Poor/absent Child abuse Child Other neg. Assault, not Suicide Other suprvsn neglect abuse
SupervisionPercentage of Drowning Deaths By Percentage of Drowning Deaths By Supervision Level Supervisor Impairment n=2440 (Supervision="no, not needed" excluded) n=2104 No, but needed 34% No 12% Yes No, not 50% needed 14% Yes UK 39% 38% NotSpecified 8% Unable to determine 5%
Supervision LevelDrowning deaths only All Accidental Deaths in SystemNot Specified 201 8.2% Not Specified 1731 9.6%No, not No, notneeded 336 13.8% needed 5610 31.1%No, but No, butneeded 831 34.1% needed 2265 12.6%Yes 960 39.3% Yes 7555 41.9%Unable to Unable todetermine 112 4.6% determine 881 4.9%Total 2440 100.0% Total 18042 100.0%
Type of Impairment (Supervision="no, not needed" excluded) (n=1052 marked "impaired" in 2104 cases) Categories are not mutually exclusive600 561 62 of 2104500 cases were supervisor drug400 and/or alcohol impaired. 331 (Count of 62 is300 mutually exclusive.)200 112 120100 30 38 14 5 0 Drug Alcohol Asleep Distracted Absent Illness Disability Other
Toddler Juan CardenasFeb. 2012: A one-year-old child from Indiana who died Wednesday is believed tohave drowned in the baptismal pool of a church where he regularly attended daycare.Employees at Praise Fellowship Assembly of God in Indianapolis found Juan CardenasWednesday afternoon in a pool used to perform baptisms, which was filled withabout two feet of standing water. The toddler had become lost in the church shortlyafter arriving for daycare.Investigators are now interviewing witnesses to determine what went wrong at thedaycare center, which was cited for 18 minor violations the last time it was inspectedin November 2011. "We have our homicide investigators here, along with membersof our child abuse team trying to determine how the child actually got there,""This was preventable," Emily Barrow of Child Care Answers in Indianapolis told theStar. "Licensed facilities have a sight and sound regulation; child care ministries donot."
Teenager Robert HarrisSeptember 2011: A 17-year-old Federal Way boy diedSaturday evening after swimming in Lake Tapps, areservoir thats a popular recreational destination.Harris had been at a family barbecue when he wentinto the lake to retrieve a football. He then began tostruggle and disappeared into the water, according tothe reports. Family members swam out to where hehad last been seen but couldnt find him.On the Lake Tapps North Park website, a warning states that the lake is fed by water froma glacier: "Lake Tapps water averages 50 degree in the summers — this is not the same asair temperature.“ Paramedic Jewitt said that the cold water "is very debilitating ... evenfor a strong swimmer.“He said it seemed to him that his unit was answering an average of two calls a yearreporting drowning at Lake Tapps. "Theyre horrible calls to run, just horrible," he said
Little Abal GavinBAKERSFIELD, Calif. — A 2-year-old boy has died,less than a day after he fell into a backyard poolduring a family gathering….the door was left opento the pool….Police are calling this case a tragicaccident, and no charges will be filed.
Baby Ishan PatelFeb 2012. "From the day her son was born,Neha Patel said, she hated him. On Thursday,that hatred reached a fatal level, according tothe Polk County Sheriffs Office. Investigatorssaid Patel slapped Ishan, her 1-year-old son,then purposefully left him alone to drown in abathtub half full of water at their Lakelandhome. When she returned 10 minutes laterand found him unconscious, she refused toperform CPR, even though she knew theprocedure, the sheriffs office said.This absolutely makes me sick," Polk CountySheriff Grady Judd after hearing of Patelsconfession. "To think of the torture that thischild endured is beyond imagination.
Toddler Grant HayesMay 2011, Enumclaw, WA: The water was toodeep, the river too strong and the boy tooyoung. He was 2½, and he died Friday. He’dbeen camping with his parents in theGreenwater area, east of Enumclaw. Oneuncertain step, and the rain-swollenGreenwater River swept him away, accordingto Ed Troyer, Pierce County Sheriff’sspokesman.The boy’s mother and a family friend, who also brought children, were makinglunch at a campsite near the river. The boy’s father was due to arrive later. Bothparents work for local law enforcement agencies. Troyer declined to say whichones. The boy was sitting in a small chair, waiting for lunch. The next moment,he was gone.Troyer said the incident serves as a grim warning to holiday campers andpicnickers: “Stay out of creeks and rivers,”
CPS HistoriesPercentage of Drowning Deaths Percentage of Drowning Deaths by By Open CPS Case with Child History of Child Maltreatment n=2440 n=2440 No No 66% 171 of 43% Yes Yes 252 cases 5% 10% were identified UK thru CPS 29% UK 47% Of the yes, 50% were infants
Caregiver Responsibility StudyVignette Caregiver Some Caregiver Significant? not responsibility responsible- P value responsible- neglect definitely no neglect related neglect10 month old in 1.4% 37.3% 61.2%bathtub-momanswers doorbellMom had prior 0.4% 28.2% 71.4% .018CPS 3 yearsearlier3 yr old poor boy 2.9% 56.2% 40.9%at picnic,wanders topond. ParentsdistractedSame story-but 2.5% 51.5% 46% .500boy not poor
What to Do?http://www.bakersfieldnow.com/news/local/Police-investigate-the-near-drowning-of-a-2-year-old-139787643.html -
Secondary Prevention:Primary Prevention: Helping hurt kids andKeeping kids from families: Improve CPsgetting hurt Practices Media campaign Provider education Improve reporting Parent education Improve assessments Patient education Provide services School Program Improve services Community Project Change policy Other prevention project Pass a law New policies Train workers New/amended laws Increase funding Modify consumer product Recall consumer product Modify space Other, specify
Media campaign 145 School program 64 Community safety project 170 CDR Team Provider education 70 Parent education 194Recommendations Public forum 28 Other education 58 and Actions New policy 35 Revised policy 22 New program 18 New services 15 Expanded services 19 New law 47 Amended law 23 Enforcement of law 31 Modify consumer product 8 Recall consumer product 2 Modify public space 20 Modify a private space 30 Other 46 Total 1045