Michigan Child Death Review

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					        A Guide for Effective
         Child Death Reviews

Developed by the Michigan Child Death Review Program
       Michigan Department of Human Services
                        and
   the National MCH Center for Child Death Review
     Health Resources and Services Administration

          Michigan Public Health Institute



                   Updated May 2005
                         Guide to Effective Reviews
               The Goal of Child Death Review is to understand
          Why children die and to take action to prevent other deaths.



To Use this Guide
This guide can be used as you review specific causes of child deaths. Use the guide to help
determine what records should be brought to your meeting, what risk factors to evaluate, the types
of services your team should ensure are provided, and evidence-based prevention activities your
team may consider.

Effective review team meetings require team members to:

         Come prepared with information on the deaths to be reviewed
         Share their information openly and honestly
         Seek solutions instead of blame

At each case review, members should seek to answer:

         Is the investigation complete, or should we recommend further investigation? If so, what
          more do we need to know?
         Are there services we should provide to family members, other children and other persons
          in the community as a result of this death?
         Could this death have been prevented and if so, what risk factors were involved in this
          child’s death?
         What changes in behaviors, technologies, agency systems and/or laws could minimize
          these risk factors and prevent another death?
         What are our best recommendations for helping to make these changes?
         Who should take the lead in implementing our recommendations?
         Is our review of this case complete or do we need to discuss it at our next meeting?




“Never doubt that a small group of thoughtful, committed citizens can change the world; indeed it is
                          the only thing that ever has.” - Margaret Mead

               Additional copies may be downloaded at www.keepingkidsalive.org
                         Effective Reviews - Natural Deaths to Infants


Facts                                                               Services to Consider
   Natural deaths to infants comprise the largest group of            Bereavement services.
    child deaths in the state, almost 50% of all deaths. These         Specialized burial services for stillborn or fetal deaths.
    include deaths due to congenital anomalies, infants born           Preconception and pregnancy planning.
    prematurely and of low birth weight, respiratory                   Specialized services for surviving siblings.
    complications, infections, and other medical conditions.           Genetic counseling for certain congenital anomalies.
   Infant death rates are calculated differently than other
    child death rates. They are the number of deaths per            Improvements to Agency Practices
    1,000 live births.                                                 Much of prevention is closely related to agency practices
   The greatest numbers of natural deaths are of infants who           surrounding maternal health. Many of these practices are
    die within the first 24 – 48 hours of life. Black infants are       considered prevention and described in the next section.
    more than twice as likely to die in their first year than
    white infants.                                                  Effective Prevention Actions
   Many infant deaths can be prevented through                        Ensure that all women have available preconception care
    improvements to maternal prenatal health.                           and counseling and prenatal care that is acceptable,
   Prematurity refers to infants born at less than 37 weeks            accessible and appropriate.
    gestation, and low birth weight refers to infants weighing         Ensure that all women have postpartum care options
    less than five pounds, five ounces at birth.                        available that include pregnancy planning.
                                                                       Work with hospitals and providers to make sure that
Records Needed                                                          every infant that leaves the hospital has a primary care
  Public Health birth records                                          provider established.
  Health records for well and sick visits and immunizations           Improve local provider knowledge of pre-conception
  Death certificates                                                   health care issues.
  Prenatal care records                                               Improve emergency response and transport systems.
  Hospital birth records                                              Provide maternal and infant support services to improve
  Emergency Department records                                         the social/psychological environment for women and
  Any support services utilized, including WIC and                     families at risk.
   Family Planning                                                     Encourage the comprehensive assessment of risks due to
  Police reports                                                       STIs, substance abuse including alcohol, smoking,
  Prior CPS reports on caregivers                                      domestic violence, depression, social support, housing,
  Home visitation reports                                              employment, transportation, etc. by all local providers
                                                                        and perhaps as a local hospital delivery policy.
Risk Factors                                                           Develop and distribute community resource directories to
   Prior pre-term delivery.                                            raise awareness of where to go for help and services.
   Previous infant or fetal loss.                                     Provide mentoring, support, outreach and advocacy at
   Inadequate prenatal care (late entry, missed                        the community level utilizing paraprofessionals,
    appointments).                                                      indigenous health workers and faith-based initiatives.
   Medical conditions of the mother.                                  Develop systems to provide transportation and childcare
    -    Maternal age (under 20, over 35)                               to women seeking prenatal care.
    -    Infections, including sexually transmitted (STI)              Coordination of care between programs and parts of the
    -    Hypertension                                                   health care system.
    -    Diabetes                                                      Forums to raise awareness of consumers, providers and
    -    Poor nutritional status                                        policy makers of infant mortality issues.
    -    Obesity                                                       Local community/business/health care partnerships to
    -    Short inter-pregnancy interval                                 broaden the number of stakeholders.
   Poverty.                                                           Enhanced community education to include unplanned/
   Substance, alcohol and tobacco use.                                 unwanted pregnancy prevention, including teen
   Stressors and lack of social support.                               pregnancy prevention services and early detection of
   Less than 12th grade education.                                     signs and symptoms of pre-term labor.
   Unintended pregnancy.
   Unmarried or lack of male involvement in pregnancy.             For More Information
   Physical and emotional abuse of mother.                            National Fetal and Infant Mortality Review Program
                                                                        www.acog.com
                                                                       March of Dimes
                                                                        www.modimes.org
                        Effective Reviews - Natural Deaths Ages 1 - 18




Facts                                                               Services to Consider
   Death from natural causes is the second leading cause of           Bereavement services.
    mortality to children over one year of age, following              Specialized services for surviving siblings.
    unintentional injuries.                                            Crisis responses for friends of decedent, including in
   Cancer, congenital anomalies and cardiac conditions are             schools.
    the top three causes of natural death.                             Burial payments for families needing financial assistance.
   Fatalities from illnesses such as asthma, infectious
    diseases and some screenable genetic disorders, under           Improvements to Agency Practices
    certain circumstances, can and should be prevented.                Were services in place for chronically ill children?
   Asthma affects approximately five million children a year          Were referrals made and followed up for repeat health
    in the U.S. The asthma death rate for ages 19 years and             care visits and other care?
    younger increased by 78% between 1980 and 1993, many               Were efforts made to obtain full complement of available
    believe due to environmental conditions.                            public services for eligible families?
   Failure to seek medical care for ill children can be fatal in      Was investigation coordinated with CPS and other
    some instances.                                                     agencies?
                                                                       Was death referred to medical examiner if medical neglect
Records Needed                                                          was suspected?
  Public Health birth records
  Pediatric records for well and sick visits                       Effective Prevention Actions
  Death certificates                                                  Provide coordinated wrap-around services for chronically
  Hospital birth records                                               ill children.
  Emergency Department records                                        Develop community education campaigns surrounding
  Public Health immunization records                                   chronic health problems in children, such as asthma.
  Names, ages and genders of other children in home                   Ensure that schools are provided sufficient information
  Police reports                                                       and training for children with chronic health problems.
  CPS reports on caregivers and child                                 Conduct assessments and seek removal of suspected
  Home visitation reports                                              environmental health hazards.
  ISD records, if applicable
                                                                    For More Information
Risk Factors                                                           American Academy of Pediatrics
   Children with chronic health conditions or congenital               www.aap.org
    anomalies.                                                         American Lung Association
   Exposure to environmental hazards, especially of                    www.lungusa.org
    vulnerable children.                                               Easter Seal Society
   Non-compliance with prescribed treatment regimens.                  www.easter-seals.org
   Parental or caregiver failures to seek adequate medical            March of Dimes
    attention.                                                          www.modimes.org
                                    Effective Reviews – Asthma




Facts                                                              Services to Consider
   Asthma is one of the most common chronic diseases of              Bereavement services for family and friends.
    childhood.                                                        Crisis responses for friends of decedent, including in
   An estimated 4 million children under age 18 have had an           schools.
    asthma attack in the past 12 months.                              Burial payments for families needing financial assistance.
   Asthma fatalities can usually be prevented.
   The asthma death rate for ages 19 and younger increased        Improvements to Agency Practices
    by 78% between 1980 and 1993, many believe due to                 Were referrals made and followed up on for health care
    environmental conditions.                                          visits for poorly controlled asthma and other care?
   Failure to seek medical care for asthmatic children can be        Were efforts made to obtain full complement of available
    fatal.                                                             public services for schools and eligible families?
   Even though asthma cannot be cured, it can almost                 Was investigation coordinated with CPS and other
    always be controlled.                                              agencies?
                                                                      Was death referred to medical examiner if medical neglect
Records Needed                                                         was suspected?
  Death certificates                                                 If the child was in foster care, were there asthma triggers
  Pediatric records for well and sick visits, including info on       present in the foster home?
   medications prescribed, asthma management plan,
   pulmonary function testing, specialty referrals                 Effective Prevention Actions
  Emergency Department/EMS records                                   Develop community education campaigns regarding
  Any support services, such as school asthma management              childhood asthma.
   programs                                                           Ensure that schools are provided sufficient information
  CPS reports on caregivers and child                                 and training to respond to students’ asthma attacks.
                                                                      Conduct assessments and seek removal of suspected
Risk Factors                                                           environmental health hazards.
   Lack of steroid inhalers or peak flow meters                      Educate health care providers on the need to prescribe
   African-American and low-income children; children                 corticosteroids, the need for timely referrals to specialists,
    with allergies                                                     and the need to limit refills for rescue medications
   Children living in crowded conditions, which leads to              without a physician visit or attention.
    increased exposure to allergens and infections                    Educate parents and children on the severity of asthma
   Exposure to environmental hazards such as tobacco                  and its dangers.
    smoke, air pollution, strong odors, aerosols and paint            Develop system for pharmacies to notify practitioners of
    fumes                                                              excessive bronchodilator use by their patients.
   Non-compliance with prescribed treatment regimens
   Parental or caregiver failures to recognize seriousness of     For More Information
    attacks and seek adequate medical attention                       American Academy of Pediatrics
                                                                       www.aap.org
                                                                      American Lung Association
                                                                       www.lungusa.org
                                                                      Centers for Disease Control and Prevention
                                                                       www.cdc.gov
                                                                      Allergy/Asthma Network Mothers of Asthmatics
                                                                       www.aanma.org
                         Effective Reviews – Children with Disabilities

Facts                                                                Services to Consider
   Based on underlying cause only, developmental                       Bereavement services for parents and other family
    disabilities are the 5th leading cause of non-traumatic              members.
    death for children 1-14 years and 3rd leading cause for             Burial payments for families needing financial assistance.
    children 15-19 years.
   Nine percent of all children have disabilities.                  Improvements to Agency/School Practices
   Child abuse is estimated to cause approximately 25% of              Do professionals know how to appropriately manage and
    all developmental disabilities in children.                          respond to disability?
   Children with disabilities are at the greatest risk of burn-        Are parents adequately educated to care for and manage
    related deaths and injury.                                           disability and health safely, including use of medical
   Children with disabilities are abused at approximately               equipment, and recognizing signs of distress and what
    twice the rate of children without disabilities.                     reaction is needed
   The most common form of homicidal event against                     Is there a team approach to identify and respond to risk
    children with cerebral palsy is starvation.                          factors of children with disabilities?
   Immobility is the single best predictor of mortality risk of        Are there appropriate autopsy protocols for children with
    children with disabilities, followed by feeding ability.             disabilities?
   Function, rather than diagnostic category, is most                  Do schools have effective information and training about
    predictive of early mortality.                                       disability, and adhere to best practices in use of Positive
   Aspiration, constipation, dehydration and epileptic                  Behavioral Services?
    seizures are the four major health issues that can cause            Do newborns with disabilities leaving hospitals have care
    death in people with developmental disabilities. The 1 st            plans, service coordinators and follow-up plans?
    three can go unrecognized until major illness or death.             Were parents of children with disabilities in poverty
   Children with disabilities may not be able to express                referred to Medicaid, EPSDT and other free health
    discomfort or indicate they don’t feel well.                         insurance for children?
   It can be difficult to differentiate the disability from other      Does child have access to effective medical care for
    signs of abuse.                                                      complexity of disability?
                                                                        Did parents have sufficient support, including respite
Records Needed                                                           care?
  Autopsy reports
  Birth records if under age one                                    Effective Prevention Actions
  Emergency Department Records                                         Support parents adequately to provide safe, effective care.
  Police Reports                                                       Collaborate among disability agencies and child abuse
  Prior CPS reports on caregivers                                       protection agencies.
  Any support services utilized                                        Educate caregivers, schools and other professionals to
  Medical records and medication records                                recognize health danger signs.
  School records                                                       Teach children with disabilities fire safety and survival
                                                                         skills and develop emergency plans for them.
Risk Factors                                                            Train parents of children with disabilities on subjects of
   Reduced mobility                                                     neglect and sexual abuse.
   Feeding difficulty                                                  Ban or closely regulate use of restraints for children with
   Feeding tube                                                         disabilities by schools, families and service agencies.
   Use of restraints                                                   Identify trends and direct training needs; recommend
   Quality of supervision / Multiple supervisors                        development and/or modification of provider policies;
   Competency of supervisor to manage disability                        modify state policies to address systemic issues that are
   Poorly controlled seizures                                           identified during review.
   Prematurity and extreme prematurity                                 Develop medical homes for children with disabilities
   Complex, uncommon medical issues                                     using coordination of care model.
   Parents not trained to recognize symptoms
                                                                     For More Information
   Lack of medical continuity/follow-up by caretakers
                                                                        Easter Seal Society
   Lack of suitable childcare
                                                                         www.easterseals.com
   Unrecognized disability
                                                                        March of Dimes
                                                                         www.modimes.org
                   Effective Reviews - Sudden Infant Death Syndrome
Facts                                                              Services
   Sudden Infant Death Syndrome (SIDS) is the sudden                 Bereavement services for parents and other family
    death of an infant under one year of age, which remains            members.
    unexplained after a comprehensive investigation. This             Referral to Tomorrow’s Child for professional and peer
    must include an autopsy, examination of the death scene            support.
    and review of the baby’s health history.                          Provision of cribs or beds for other children still in home.
   SIDS is a diagnosis of exclusion and can only be made if          Safety assessment by CPS if neglect was suspected.
    there is no other possible cause of death. If the death           Burial payments for families needing financial assistance.
    scene indicates there was a possibility of suffocation, SIDS      Provide links to services such as family planning.
    should not be listed as the cause of death.                       Critical Incident Stress Debriefing for persons responding
   Most SIDS occurs to babies between two and four months             to scene.
    old, during winter months. African American and
    American Indian SIDS rates are two to three times higher       Improvements to Agency Practices
    than the white SIDS rate.                                         Are investigations coordinated with medical examiners,
   The mechanism causing SIDS is still unknown, although              law enforcement and CPS?
    many believe that SIDS occurs when an infant is at a              Are autopsy protocols in place, which include a process
    vulnerable age, is exposed to environmental risk factors           for sending scene investigation materials to the
    and has a neural defect that prevents the child from               pathologist performing the autopsy?
    responding to oxygen depletion.                                   Are comprehensive scene investigations conducted at the
   The National Back to Sleep campaign has reduced the                place of death, as soon as possible, including scene
    SIDS rate by more than half since 1994.                            reenactments and interviews?
                                                                      Are referrals made for bereavement services?
Records Needed at Review                                              Are high-risk families with newborns and young infants
  Autopsy reports                                                     provided prevention services?
  Scene investigation reports and recreation photos                  Is a process in place to contact the Consumer Product
  Prenatal, birth and health records                                  Safety Commission when faulty products could be
  Interviews with family members                                      involved in causing a death?
  Child Care Licensing investigative reports
  EMS run reports                                                 Effective Prevention Actions
  Emergency Department reports                                       Education at childbirth classes and in hospitals to
  Prior CPS history on child, caregivers and person                   expectant and new parents on safe infant sleep
   supervising child at time of death                                  environments.
  Criminal background checks on person supervising the               In-hospital assessments by nurses with parents to assess a
   child at time of death                                              baby’s sleep environment when he/she goes home.
  Reports of home visits from public health or other                 Crib distribution programs for families.
   services                                                           Smoking cessation education and support for pregnant
  Any information on prior deaths of children in family               and parenting women and other caregivers.
                                                                      Working with hospitals and providers to make sure that
Risk Factors                                                           every infant that leaves the hospital has a primary care
   Infants sleeping on their stomachs.                                provider established.
   Soft infant sleep surfaces and loose bedding.                      “Back to Sleep” and other safe sleep campaigns.
   Maternal smoking during pregnancy.                                Specific messages targeted to families and childcare
   Second-hand smoke exposure.                                        providers who traditionally practice stomach sleep.
   Overheating.                                                      Education to health care providers on giving guidance on
   Prematurity or low birthweight.                                    SIDS risk reduction to parents and caregivers.
   Heavy or soft bedding and other objects near infant.              Licensing requirements for childcare providers on safe
   Faulty design of cribs or beds.                                    sleep environments and infant sleep positions.
   Other persons sleeping with child.
   Obesity, fatigue, drug or alcohol use by persons               For more information
    supervising or sleeping with infant.                              The National SIDS Resource Center
   Poor supervision at time of death.                                 http://www.sidscenter.org/
   Family’s inability to provide safe sleep or play                  The American Academy of Pediatrics
    environment for infant.                                            http://www.aap.org/
                                                                      Consumer Product Safety Commission
                                                                       http://www.cpsc.gov/
                                                                       Tomorrow’s Child/Michigan SIDS
                                                                       http://www.tomorrowschildmi.org/
                                      Effective Reviews - Suffocation

Facts
   Suffocation is caused by either:                                  If hanging, child’s developmental age consistent with
     Overlay: a person who is sleeping with a child rolls             activity causing strangulation.
          onto the child and unintentionally smothers the child.      Family’s inability to provide safe sleep or play
     Positional asphyxia: a child’s face becomes trapped in           environment for child.
          soft bedding or wedged or trapped in a small space          Prior child deaths or repeated reports of apnea episodes
          such as between a mattress and a wall or couch               by caregiver.
          cushions.
     Covering of face or chest: an object covers a child’s face   Services
          or compresses the chest, such as plastic bags, heavy        Bereavement and crisis services for family members and
          blankets or furniture.                                       friends.
     Choking: a child chokes on an object such as a piece of         Provision of cribs/other beds for children still in home.
          food or small toy.                                          Safety assessment by CPS if neglect was suspected.
     Confinement: a child is trapped in an airtight place such       Burial payments for families needing financial
          as an unused refrigerator or toy chest.                      assistance.
     Strangulation: a rope, cord, hands or other objects             Critical Incident Stress Debriefing for persons
          strangle a child.                                            responding to scene.
   Infants and toddlers are most often the victims.
   The majority of suffocations occur to infants while sleeping   Improvements to Agency Practices
    in unsafe environments.                                           Are investigations coordinated with medical examiners,
   It is often difficult to distinguish an unintentional              law enforcement and CPS?
    suffocation from SIDS or a homicide. Autopsies and scene          Are autopsy protocols in place?
    investigations are essential.                                     Are comprehensive scene investigations conducted at
   Rates of infant suffocations are increasing as investigators       place of death, as soon as possible, including scene
    better distinguish suffocation from SIDS.                          reenactments and interviews?
                                                                      Are referrals made for bereavement and crisis services?
Records Needed at Review                                              Are high-risk families with newborns and young infants
  Autopsy reports                                                     provided prevention services?
  Scene investigation reports and recreation photos                  Is CPS notified in cases of suspicious deaths?
  Interviews with family members                                     Is a process in place to contact Consumer Product Safety
  Child Care Licensing investigative reports, if occurred in          Commission if death involved consumer product?
   child care setting
  EMS run reports                                                 Effective Prevention Actions
  Emergency Department reports                                       Education at childbirth classes and in hospitals to
  Prior CPS history on child, caregivers and person                   expectant and new parents on safe infant sleep
   supervising child at time of death                                  environments.
  Child’s health history                                             In-hospital assessments by nurses with parents to assess
  Criminal background checks on person supervising child at           babies’ sleep environments.
   time of death                                                      Culturally competent public education campaigns on
  Reports of home visits from public health or other services         safe infant sleep environments.
  Any information on prior deaths of children in family              Crib distribution programs for needy families.
  Any information on prior reports that child had difficulty         Education to professionals on risks of infant suffocation.
   breathing                                                          Notification to CPSC and continued product safety
  Downloaded information from apnea monitors                          recalls on choking and strangulation hazards.
                                                                      Licensing requirements for child care providers on safe
Risk Factors                                                           infant sleep environments and sleep position.
   Unsafe infant sleep environment.
   Prone position of infant while sleeping.                       For More Information
   Heavy or soft bedding and other objects near infant.              The National SIDS Resource Center
   Faulty design of cribs, beds or other hazards.                     http://www.sidscenter.org/
   Other persons sleeping with infant.                               The American Academy of Pediatrics
   Obesity, fatigue, or drug or alcohol use by persons                http://www.aap.org
    supervising or sleeping with infant/child.                        Consumer Product Safety Commission
   Poor quality of supervision at time of death.                      http://www.cpsc.gov/
   Child’s ability to gain access to objects causing choking or      Tomorrow’s Child/Michigan SIDS
    confinement.                                                       http://www.tomorrowschildmi.org/
                                            Effective Reviews - Fires


Facts
   Most fire-related deaths to children occur in house fires,   Services
    and the cause of death is most often asphyxia due to            Bereavement and crisis services for family members and
    smoke inhalation, not burns.                                     friends.
   Toddlers, especially African American and American              Provision of emergency shelter for surviving family
    Indian males, are most often the victims.                        members.
   The vast majority of fire deaths occur in low-income            Safety assessment by CPS if neglect was suspected.
    neighborhoods.                                                  Burial payments for families needing financial assistance.
   Children playing with matches or lighters start most of         Critical Incident Stress Debriefing for persons responding to
    the fires that kill children.                                    scene.
   Young children tend to hide from the fire, making it            Juvenile fire-setter counseling when appropriate.
    difficult for family members or rescue personnel to
    locate them.                                                 Improvements to Agency Practices
   Functioning smoke detectors are highly protective               Are investigations coordinated with medical examiner,
    against fire fatalities.                                         police, fire marshal and CPS?
   The risk of death in a fire increases significantly when a      Are referrals made for bereavement and crisis services?
    supervising adult is intoxicated.                               Are high-risk families with young children provided
                                                                     prevention services?
Records Needed at Review                                            Do well-baby or other routine health visits include
  Autopsy reports                                                   questioning parents about smoke detectors?
  Scene investigation reports and photos                           Is there a process in place to contact Consumer Product
  Fire marshal reports that include source of fire and              Safety Commission when faulty products lead to death?
   presence of detectors                                            Do mental health providers routinely screen and provide
  EMS run reports                                                   treatment for child fire-setters?
  Emergency Department records
  Information on zoning or code inspections and                 Effective Prevention Actions
   violations                                                       Smoke detector distribution programs that are targeted in
  Prior CPS history on child, caregivers and persons                low-income neighborhoods, providing non-removable,
   supervising child at time of death                                lithium batteries.
  Names, ages and genders of other children in home                Legislation requiring installation of detectors in new and
  Criminal background checks on persons supervising                 existing housing, especially when combined with
   child at time of death                                            multifaceted community education and detector give-
  Reports of home visits from public health or other                aways.
   services                                                         Risk Watch or similar programs in schools, preschools and
  Any information on prior deaths of children in family             child care settings to teach fire safety and home fire escape.
                                                                    Utilization of mobile “Smoke Houses” by fire departments
Risk Factors                                                         to teach children how fires start, how fast they can spread,
   Lack of working smoke detectors in the home.                     and how best to escape a burning house.
   Poor quality of supervision at time of death.                   Codes requiring hard-wired detectors in new housing stock.
   Drug or alcohol use by supervising adults.                      Passage and enforcement of local ordinances regarding the
   Child’s ability to gain access to lighters, matches or           inspection of rental units for fire safety, especially for the
    other incendiary devices.                                        presence of working smoke detectors.
   Members of household falling asleep while smoking or
    leaving candles burning.                                     For More Information
   No exposure of victim to fire safety education.                 Harborview Injury Prevention and Research Center:
   Lack or no practice of home fire escape plan.                    http://depts.washington.edu/hiprc/
   Use of alternative heating sources, substandard                  United States Fire Administration:
    appliances or outdated wiring.                                   http://www.usfa.fema.gov/safety/
   Failure of property to maintain code requirements.              National Fire Protection Association:
   Lack of prompt fire rescue response.                             http://www.nfpa.org/Education/index.asp
                                                                    National SAFEKIDS
                                                                     www.safekids.org
                                       Effective Reviews - Drowning




Facts                                                         Improvements to Agency Practices
   Most drowning deaths to children occur when there is a       Are investigations coordinated with medical examiner,
    lapse in adult supervision.                                   police and CPS?
   Toddlers, especially males, are most at risk of              Are referrals made for bereavement and crisis services?
    drowning.                                                    Are high-risk families with young children provided
   Babies most often drown in bathtubs; toddlers in pools;       prevention services, including parenting skills and safety
    older children and teenagers in open bodies of water.         concerns?
   Infants can drown in water less than five inches deep,       Do well-baby visits include information about bathtub
    in less than five minutes.                                    safety for infants?
   When adequate supervision is combined with                   Is there local enforcement of building codes for pool
    approved personal flotation devices, drowning                 fencing?
    occurrences are rare.                                        Was there adequate emergency response and equipment for
   Most toddlers who drown in pools enter the water              a water rescue?
    unseen and unheard by others.
                                                              Effective Prevention Actions
Records Needed at Review                                         Strong support and local enforcement of building codes
  Autopsy reports                                                regarding proper pool and pond enclosures.
  Scene investigation reports                                   Placement of signage near bodies of water to warn of water
  EMS run reports                                                dangers such as strong currents and drop-offs.
  Prior CPS history on child, caregivers and persons            Public awareness campaigns and water safety classes for
   supervising child at time of death                             parents of young children, emphasizing constant adult
  Names, ages and genders of other children in home              supervision and use of personal floatation devices.
  Information on zoning and code inspections and                Children’s swim and water safety classes for children over
   violations regarding pools or ponds                            age four.
                                                                 Parent education at childbirth classes and well-baby visits
Risk Factors                                                      on bathtub safety for infants.
   Lack of adequate adult supervision.
   Drug or alcohol use by supervising adults.                For More Information
   Child’s ability to gain access to pools.                     The National Children’s Center for Rural and Agricultural
   Child not able to swim.                                       Health and Safety:
   Lack of use of personal floatation devices.                   http://research.marshfieldclinic.org/children/Resources/
                                                                  Drowning/drowning.htm
Services                                                         National Center for Injury Prevention and Control (Centers
   Bereavement and crisis services for family members            for Disease Control and Prevention):
    and friends.                                                  http://www.cdc.gov/ncipc/factsheets/drown.htm
   Safety assessment by CPS if neglect was suspected.           Harborview Injury Prevention and Research Center:
   Burial payments for families needing financial                http://depts.washington.edu/hiprc/
    assistance.                                                  US Consumer Product Safety Commission:
   Critical Incident Stress Debriefing for persons               http://www.cpsc.gov/cpscpub/pubs/chdrown.html
    responding to scene.                                         National SAFEKIDS
                                                                  www.safekids.org
                        Effective Reviews - Child Abuse and Neglect

Facts                                                           Services
   Abusive Head Trauma: Most child abuse deaths are the           Involving CPS in assessing the removal of remaining
    result of injuries to the head due to violent shaking,          children from the home.
    slamming or striking the head.                                 Bereavement services for parents and other family
   Blunt force injury to the abdomen: The second most              members.
    common cause of child abuse fatality is from punches or        Burial payments for families needing financial assistance.
    kicks to the abdomen leading to internal bleeding.             Critical Incident Stress Debriefing for persons responding
   Other likely causes: Smothering, drowning and                   to scene.
    immersion into hot water.
   One-time event: Although children who die from              Improvements to Agency Practices
    physical abuse have often been abused over time, a one-        Are investigations coordinated with medical examiners,
    time event often causes a death.                                law enforcement and CPS?
   Common “triggers”: Caretakers who abuse their children         Are autopsy protocols in place?
    usually cite crying, bedwetting, fussy eating and              Are comprehensive scene investigations conducted at
    disobedience as the reason they lost their patience.            place of death, as soon as possible, including scene
   Young children are most vulnerable: children under 6            reenactments and interviews?
    years of age account for four-fifths of all maltreatment       Are referrals made for bereavement services?
    deaths; infants account for roughly half of these deaths.      Are high-risk families with newborns and young infants
   Fathers and mothers’ boyfriends are the most common             provided prevention services?
    perpetrators of abuse fatalities.                              Did mandatory reporters comply with requirements of
   Mothers are more often at fault in neglect deaths.              child protection laws?
   Fatal abuse is often interrelated with poverty, domestic       Were prior inflicted injuries identified and reported?
    violence and substance abuse.                                  Did CPS conduct a full investigation and make
   The majority of children and their perpetrators had no          appropriate referrals and recommendations?
    prior contact with CPS at the time of the death.
   It can be very difficult to investigate, identify and       Effective Prevention Actions
    prosecute fatal child abuse.                                   Training hospital emergency room staff to improve their
                                                                    ability to identify child abuse injuries and improve
Records Needed at Review                                            reporting to the appropriate agencies.
  Autopsy reports                                                 Providing an advisory on the mandated reporting of child
  Scene investigation reports and photos                           abuse and neglect to local human service agencies,
  Interviews with family members                                   hospitals and physicians.
  Names, ages and genders of other children in home               Case management, referral and follow-up of infants sent
  Child Care Licensing investigative reports                       home with serious health or developmental problems.
  EMS run reports                                                 Media campaigns to enlighten and inform the general
  Emergency Department records                                     public on known fatality-producing behaviors, i.e.,
  Prior CPS history on child, caregivers and person                violently shaking a child out of frustration.
   supervising child at time of death                              Crisis Nurseries which serve as havens for parents “on
  Child’s health history                                           the edge” where they can leave their children for a
  Criminal background checks on person supervising child           specified period of time, at no charge.
   at time of death                                                Intensive home visiting services to parents of at-risk
  Home visit records from public health or other services          infants and toddlers.
  Any information on prior deaths of children in family           Education programs for parents such as the Parent
  Any pertinent out-of-state history                               Effectiveness Training (P.E.T.), the Parent Nurturing
                                                                    Program and Systematic Training for Effective Parenting
Risk Factors                                                        (S.T.E.P.).
   Younger children, especially under the age of five.
                                                                For More Information
   Parents or caregivers who are under the age of 30.
                                                                   National Clearinghouse on Child Abuse and Neglect
   Low income, single-parent families experiencing major
                                                                    http://nccanch.acf.hhs.gov/
    stresses.
                                                                   National Exchange Club Foundation
   Children left with male caregivers who lack emotional
                                                                    http://preventchildabuse.com
    attachment to the child.
                                                                   Prevent Child Abuse America
   Children with emotional and health problems.
                                                                    http://www.preventchildabuse.org
   Lack of suitable childcare.
                                                                   American Professional Society on the Abuse of Children
   Substance abuse among caregivers.
                                                                    http://apsac.fmhi.usf.edu/
   Parents and caregivers with unrealistic expectations of
    child development and behavior.
                         Effective Reviews - Motor Vehicle Deaths

Facts                                                            Services
   Motor vehicle deaths include those involving cars, trucks,      Bereavement and crisis services for family and friends.
    SUVs, bicycles, trains, snowmobiles, motorcycles, buses,        Critical Incident Stress Debriefing for persons responding
    tractors and all-terrain vehicles.                               to scene.
   Victims include drivers, passengers and pedestrians.
   Young people ages 15-20 make up 6.7% of the total            Improvements to Agency Practices
    driving population in this country, but are involved in         Are investigations coordinated with medical examiners,
    14% of all fatal crashes. Most of these crashes involve          local and state law enforcement?
    recklessness, speeding or inattention.                          Are comprehensive scene investigations conducted,
   Sixteen-year-olds driving with one teen passenger are            including type of restraint needed and used?
    39% more likely to get killed than those driving alone,         Was the primary cause of the incident determined?
    increasing to 86% with two and 182% with three or more
    teen passengers.                                             Effective Prevention Actions
   Studies show that more than 80% of all infant and toddler    Children Under 16
    car safety seats are not properly installed or used.            Lower Anchors and Tethers for Children (LATCH):
   Children weighing 40-80 pounds (ages 4-9) should be              USDOT requires all new child safety seats meet stricter
    seated in booster seats, but most are not.                       head protection standards.
   Helmets can prevent the majority of bicycle-related             Legislation linked with public education to increase
    fatalities.                                                      booster seat usage for children weighing 40 - 80 pounds.
                                                                    Child safety seat inspection programs: programs that
Records Needed at Review                                             train auto dealers, law enforcement officers and others to
  Autopsy reports                                                   provide on-site safety seat inspection and training.
  Scene investigation reports and photos                           Free or low-cost car safety seat distribution.
  Interviews with witnesses                                        Bicycle helmet laws paired with free or reduced-cost
  EMS run reports                                                   helmets to children.
  State Uniform Crash Reports with road and weather                Truck bed laws prohibiting children from riding in truck
   conditions at time of crash                                       beds; KIDS AREN’T CARGO is an education campaign
  Emergency Department records                                      discouraging truck bed riding.
  Blood alcohol and/or drug concentrations on driver               Re-engineering of roads and improved signage.
  Previous violations such as drunk driving or speeding         Children Over 16
  Any out-of-state history                                         Graduated Licensing Laws: including supervised
  Graduated Licensing laws and violations                           practice; crash and conviction free requirements for a
  Information on other crashes at the same location                 minimum of six months; limits on number of teen
                                                                     passengers; nighttime driving restrictions and manda-
Risk Factors                                                         tory seat belt use for all occupants.
Children Under 16                                                   Teen Driver Monitoring Programs: Street Watch and
   Riding in the front seat of vehicles.                            SAV-TEEN marks teen cars and allow anyone observing
   Not using or improper use of child seats and seatbelts.          poor driving habits to report them to law enforcement.
   Not wearing adequate safety equipment, especially                Law enforcement either visits the teen’s home or reports
    bicycle helmets.                                                 the incident to the parents or owner of the car.
   Unskilled drivers of recreational vehicles, such as ATVs        Driver’s Education: Customize local programs to
    and snowmobiles.                                                 emphasize most common risk factors, e.g., off-road
   Riding in the bed of a pickup truck.                             recovery, gravel roads, poor weather conditions.
   Young children playing in and around vehicles                   Seat Belts: Education to increase adolescent seat belt use
   Young children crossing streets without supervision.             and primary seat belt enforcement laws.
Children Over 16                                                    Re-engineering of roads and improved signage.
   Exceeding safe speeds for driving conditions.
   Riding as a passenger in a vehicle with a new driver.        For More Information
   Riding in a vehicle with three or more teen passengers.         National Highway Traffic Safety Administration
   Driving/riding between 12 midnight and 6:00 a.m.                 www.nhtsa.dot.gov
   Not using safety belts appropriately.                           National SAFE KIDS Campaign
                                                                     www.safekids.org
   Alcohol use by drivers or passengers.
                                                                    Ford Motor Company – Boost America!
   Riding in the bed of a pickup truck.
                                                                     www.ford.com/en/goodWorks/community/booster
   Unskilled drivers of recreational vehicles, such as ATVs
                                                                     Seats.htm?source=rt&referrer=safety_childSafety
    and snowmobiles.
                                                                    DaimlerChrysler – Fit for a Kid
                                                                     www.fit4akid.org
                                            Effective Reviews - Suicides
Facts                                                               Services
   Suicide is the third leading cause of death for adolescents,       Bereavement services for parents and other family
    following motor vehicles and firearm homicides. More                members.
    young people die from suicide than from cancer, heart              Burial payments for families needing financial assistance.
    disease, AIDS, birth defects, stroke, pneumonia, influenza         Critical Incident Stress Debriefing for persons responding
    and chronic lung disease combined.                                  to scene.
   The methods used most often to complete suicide include            School crisis response teams.
    firearms, hanging and poisoning.
   The risk for suicide is highest among young white males.        Improvements to Agency Practices
    Adolescent males of all races are four times more likely to        Are investigations coordinated with medical examiners,
    commit suicide than females. Adolescent females are                 law enforcement and Children’s Protective Services?
    twice as likely as adolescent males to attempt suicide.            Are autopsy protocols in place for suicides? Are
    There appears to be an increase in rates for ages 12-14.            toxicology screens done routinely?
   Males are more successful in their attempts because they           Are comprehensive scene investigations conducted as
    most often use firearms.                                            soon as possible, including interviews?
   Depression, coupled with significant precipitating events,         Are referrals made for bereavement services?
    leads to most suicides in young persons. Some of these             Are friends of the victims closely monitored for warning
    precipitating events may seem insignificant to adults, but          signs of suicide in schools by teachers, administrators,
    are very serious to vulnerable teens.                               janitors, bus drivers, etc?
   The school setting has been identified as a critical place to
    recognize warning signs of suicide and to implement             Effective Prevention Actions
    primary and secondary prevention activities.                       The Yellow Ribbon Suicide Prevention Campaign to help
   Cluster suicides, those committed by other teens                    youth identify places to get help when they or their
    following a friend’s suicide, are not uncommon. Any teen            friends are troubled.
    suicide should trigger watches on other vulnerable teens.          School gatekeeper training to help school staff identify
                                                                        and refer students at risk and respond to suicide or other
Records Needed                                                          crises in the school.
  Autopsy reports, including toxicology screens                       Community gatekeeper/suicide risk assessment to train
  Scene investigation reports and photos                               community members who interact frequently with teens.
  Suicide notes                                                       General suicide education to target teens to help them
  Downloads of decedent’s computer                                     understand warning signs and supportive resources.
  Interviews with family and friends                                  Screening programs, including those in schools, to
  EMS run reports                                                      identify students with problems that could be related to
  Emergency Department records                                         suicide, depression and impulsive or aggressive
  Prior CPS history on child, caregivers and person                    behaviors.
   supervising child at time of death                                  Peer support programs to foster positive peer
  Child’s mental health history, if available                          relationships and competency in social skills among high-
  School records and/or school representative at meeting               risk adolescents and young adults.
  Names, ages and genders of other children in home                   Crisis centers and hotlines.
  History of prior suicide attempts                                   Restriction of access to lethal means of suicide, including
  Substance/alcohol abuse history                                      removal of firearms in homes of high-risk teens.
  Any information on recent significant life events,                  Interventions after a suicide that focus on friends and
   including trouble with the law or in school                          relatives of persons who have committed suicide, to help
  If a firearm was used in the suicide, information on the             prevent or contain suicide clusters and to help adolescents
   storage of the firearm                                               and young adults cope effectively with the feelings of loss
                                                                        that follow the sudden death or suicide of a peer.
Risk Factors                                                           Development of assessment tools for evaluating suicide
   Long term or serious depression.                                    risk for students who are expelled from school or arrested
   Previous suicide attempt.                                           for minor offenses.
   Mood disorders and mental illness.
   Substance abuse.                                                For More Information
   Childhood maltreatment.                                            Youth Suicide Prevention Program
   Parental separation or divorce.                                     http://www.yspp.org/
   Inappropriate access to firearms.                                  National Yellow Ribbon Program
                                                                        www.yellowribbon.org
   Interpersonal conflicts or losses without social support.
                                                                       National Strategy for Suicide Prevention
   Previous suicide by a relative or close friend.
                                                                        www.mentalhealth.org/suicideprevention
   Other significant struggles such as bullying or issues of
                                                                       Suicide Prevention Resource Center
    sexuality.
                                                                        www.sprc.org
                                 Effective Reviews - Teen Homicides




Facts                                                             Services to Consider
   Youth homicides represent the greatest proportion of all         Bereavement services.
    firearm deaths. Each day in the U.S., firearms kill an           Neighborhood-based crisis intervention.
    average of 10 children and teens, even though the number         Witness protection services.
    of teens killed by firearms in the U.S. has dropped by 35%
    in the past four years.                                       Improvements to Agency Practices
   In 2000, the Youth Risk Behavior Surveillance Survey             Are comprehensive investigations conducted on all youth
    reported that almost one-fifth of the 10th and 12th graders       homicides?
    reported that they had carried a firearm within the              Are crime surveillance efforts targeted to neighborhoods
    previous 30 days for self-defense or to settle disputes.          with high rates of teen violence?
   Youth homicide is mostly a serious problem in large              Do schools have policies in place to address threats made
    urban areas, especially among black males. Homicides              to students?
    are the number one cause of death for black and Hispanic         Are witnesses to violence provided appropriate services?
    teens.
   When socio-economic status is held constant, differences      Effective Prevention Actions
    in homicide rates by race become insignificant.                  Intensive, early intervention services for high-risk
   Homicides are usually committed by casual                         parents.
    acquaintances of the same gender, race and age, using            Targeted activities in neighborhoods with high homicide
    inexpensive, easily acquired handguns.                            rates, including:
   Drug dealing and gang involvement are often the cause of          -    Enhanced police presence and gun deterrence in hot
    disputes leading to homicides.                                         spots.
   The majority of firearm homicides occur in small pockets          -    Involvement of political leaders.
    of large cities.                                                  -    Widespread mobilization of neighbors and
                                                                           community members.
Records Needed                                                        -    After-school recreation programs.
  Scene investigation reports                                        -    Neighborhood Watch.
  Police and crime lab reports                                      Interdiction of illegal guns and focused prosecution of
  CPS histories on family, child and perpetrators                    gun offenders.
  Names, ages and genders of other children in home                 Dropout prevention programs and alternative education
  Ballistics information on firearms                                 opportunities.
  Prior crime records in neighborhood                               Mentoring, therapy and bullying prevention support
  Juvenile and criminal records of teen and perpetrators             programs.
  Interviews with witnesses                                         Multi-systemic therapy for troubled youth.
  Information from gang squad
                                                                  For more information
Risk Factors                                                         Johns Hopkins Center for Gun Policy and Research
   Easy availability of and access to firearms.                      www.jhsph.edu/gunpolicy/
   Youth living in neighborhoods with high rates of poverty,        Department of Justice
    social isolation and family violence.                             http://www.usdoj.gov/youthviolence.htm
   Youth active in drug and gang activity.
   Early school failure, delinquency and violence.
   Youth with little or no adult supervision.
   Prior witnessing of violence.

				
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