This powerpoint presentation was put together by Teri Covington, Senior Program Director at the Michigan Pubic Health Institute, and presented on January 15 at our Georgia Children's Advocacy Network (GA-CAN!) Forum. This month we looked at sudden and unexpected child deaths and the 2013 Child Fatality Report.

1. Child Death Review
The Power to Prevent Deaths and
Keep Children Safe and Healthy

2. CDR is:
• An engaged, multidisciplinary community, telling a
child’s story, one child at a time, to understand the
causal pathway that leads to a child’s death to identify
pre-existing vulnerabilities and circumstances- in order
to identify how to interrupt the pathway for other
children
• ….By generating a broad spectrum of data for an
ecological understanding of the individual, community,
and societal factors that interact at different levels to
influence child health and safety
• ….Then taking action to improve systems and prevent
deaths.

3. It’s all a
about
prevention
CDR:
Where Good
Shift Happens
Moving from
Bad things happen
to
We can prevent this

4. Coordinated and Comprehensive Investigations Risk Factor Analysis
Determination of Manner and Cause Effective Recommendations
Agency Practices and Policies Prevention ACTIONS:
Systems of Care Policy, Programs, Services
Justice
Family Support
Systems Improvements Prevention

5. Child Death Review in 2014
CDR in 50
states
1250 local and
state
Guam
Department of
Defense
Tribes

7. Department of Defense
DoD directive requires CDR when a child abuse death
of an active duty soldier is suspected.
Reviews managed by Office of Family Advocacy
Army: reviews conducted at installation level;
Navy, Air Force, Marines: Command level in Washington,
DC
Approximately 50-60 per year
Navy also reviewing all SUID deaths
Annual fatality summit in DC
Major worries: deployment related;
gaming addiction; off-base families

8. By the Numbers
43 states using
the System
Over 2300
authorized users
Over 1050 CDR
teams have
recorded a
death in the
System
More than
150,000 deaths
have been
entered
• 99% deaths
• 54% infants
• 75% cases from
2005-2012
• 59% males
• 51% natural deaths;
24% accidents

9. Using the Review to Take Action to
Prevent Other Deaths

10. Translating CDR Data into Action
• 50,000 plus recommendations
13,000 and more interventions

11. Transportation

12. Public Health

13. Scope of Deaths
All
preventable
child deaths
Potential child
abuse or
neglect related
deaths Deaths
known or
open to
CPS
Reviewing Maltreatment Deaths
CDR
Legislative
mandated panels
and/or citizens
review Panels/
Internal
Reviews/audits
WE NEED A
CLOSER LOOK
HERE

14. Data Source
Year
2000 2001 2002 2003 2004 2005
FCANS
Reconciliation Audit 129 133 140
Not
conducted
Not
conducted 185
Vital Statistics Death
Statistics Master File 21 30 23 30 20 21
Supplemental
Homicide File 79 77 78 90 76 82
Child Abuse Centeral
Index 34 24 30 18 36 59
Child Welfare
Services/Case
Management System 21 50 59
Not
included
Not
included
Not
included
Child Death Review
Teams - FCANS 62*
116 105 134 107 124
California:
Child Maltreatment Deaths Reported to Multiple Data
Sources, 2000-2005

15. Major Policy Changes Made Following Reviews
186 deaths in 1999-2001 264 findings
170 deaths in 2002-2004 172 findings
9% drop in deaths 35% drop in findings
Vincent J. Palusci, Steve Yager, Theresa M. Covington. Effects of a Citizens Review Panel in preventing child
maltreatment fatalities, Child Abuse and Neglect, 09: September

18. High level of interest from:
• Federal partners
HRSA MCHB, ACF, NTSB, NHTSA, CPSC,
SAMHSA, CDC, DOD, NTSB Study on Non-
Users of Car Seats
• Industry: pool, window and crib
manufacturers
• Advocacy Groups: Parent Heart Watch,
Kids and Cars, Safe Kids
Local reviews effect national policy…..

19. DATE TO ACTION
Using the Data for National Policy
 Release of special reports, Injury
Prevention Supplement
 Release of counts
 Dissemination of data base to researchers
 Understanding Limitations of Data and
Data Quality