Applying Lessons Learned from Child Fatality Reviews to Preventing

Fatalities and Near Fatalities

David P. Kelly, J.D., M.A.Administration for Children and Families, Children’s Bureau

Liz Oppenheim, J.D.Walter R. McDonald & Associates, Inc.

Ying-Ying Yuan, Ph.D.Walter R. McDonald & Associates, Inc.

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Conducted 9/26/2011 through 9/25/2012 Study Purpose ◦ Identify promising practices for fatality reviews

and furthering collaboration among reviews

Study Components◦ Literature Review◦ Review of Recommendations and Outcomes◦ Site Visits/Telephone Interviews◦ National Meeting

Study Overview

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Developing Best Practices for Fatality Reviews, Part One: A Tool for Planning and Self-Assessment

Developing Best Practices for Fatality Reviews, Part Two: Summary of Findings

Fatality Review Teams: A Literature Review A Review of State and Local Fatality Review

Team Reports: Recommendations and Achievements

Study Products

Study Context Child Abuse and Prevention Treatment Act

(CAPTA)

The Child and Family Services Improvement and Innovation Act of 2011

GAO Report: Child Maltreatment: Strengthening National Data on Child Fatalities Could Aid in Prevention (July 2011)

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The overall rate of child fatalities was 2.10 deaths per 100,000 children.

81.6% of all child fatalities were younger than 4 years old.

Boys had a higher child fatality rate than girls

◦ 2.47 boys per 100,000 boys in the population◦ 1.77 girls per 100,000 girls in the population

Nearly 90 percent (86.5%) of child fatalities were comprised of African

American (28.2%), Hispanic (17.8%), and White (40.5%) victims.

Four fifths (78.3%) of child fatalities were caused by one or more parents.

Child Maltreatment Fatalities, 2011

Fatality Review Structures & Processes

◦The different types of reviews◦Membership◦Governance and structure◦Case information and data◦Shared perspectives

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50 States and the District of Columbia have an active CDR program (at the State and/or local or regional level)

Many child welfare agencies conduct internal child fatality reviews

200 Fetal and Infant Mortality Review (FIMR) programs in 40 States

144 Domestic Violence Fatality Review (DVFR) teams at the State and local level

Fatality Reviews

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Child Fatality

State Child Fatality Review

Internal Child Welfare Agency

Review

Citizen Review Panel

Fetal & Infant Mortality Review

Domestic Violence Fatality

Review

The Web of Reviews

Regional Child Fatality Review

Local Child Fatality Review

Maternal

Mortality

Review

Elder Death Review

Military Child Fatality Review

Military Domestic

Violence Fatality Review

Fatality Review Structures & Processes Membership

◦ All are multidisciplinary◦ May not always have all the needed representatives

Administrative Homes◦ Many different administrative homes

Data collection◦ All team processes include data collection activities◦ For some teams, legislation provides access to needed

information◦ Some teams rely on information brought to reviews by

team members◦ Some teams conduct interviews with family members

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Fatality Review Structures & Processes

Authorizing legislation and policy◦ Most States have legislation authorizing or enabling

CDR◦ CRPs required as part of 1996 amendments to CAPTA◦ FIMRs are commonly guided by State public health law◦ Importance of legislation for DVFR teams acknowledged

in the literature Purpose & Timing

◦ Team purposes within types of teams vary◦ Retrospective ◦ Immediate

Scope of Review◦ Varies widely within types of fatality review teams

Shared Perspectives Deaths and serious injuries are sentinel events. They are markers for the health and safety of a community. There are multiple environmental, social, economic, health

and behavioral factors that may be related to child fatalities These factors are so multidimensional that responsibility for

a death or injury does not belong to any one agency or organization.

Reviews focus on what went wrong and how can we fix it, not who is at fault and who should we blame.

The best reviews are multi-disciplinary.

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Prevalence and Types of Recommendations: Review of Reports Most of the recommendations were for:

◦ increasing public awareness and education ◦ improving policies and legislation◦ strengthening organizational capacity

Agency, persons, or organizations often not identified

Many global statements indicating that parents should make specific changes in behavior or that communities should provide particular supports or services

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No mention of collaboration to enhance injury prevention

o CDR and FIMR teams made recommendations regarding SIDS

o DVFR teams acknowledged the impact of DV on children

All teams acknowledged that collaboration among many agencies and providers was necessary in order to effectively implement recommendations

Prevalence and Types of Recommendations: Review of Reports

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Prevalence and Types of Recommendations: Review of Selected NCDRCRS Records CAN Related Recommendations

◦ 78.8 % of the recommendations pertained to some type of educational activity

◦ 28.5 % of the recommendations were for parent education

Non-CAN Related Recommendations◦ 78.8 % of the recommendations pertained to some

type of educational activity◦ 27.5 % of the recommendations were for parent

education

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Commitment to prevention◦ Each team member must commit to use review information to

educate their own agencies and advocate for needed changes

Dissemination strategies◦ Disseminate reports far and wide ◦ Select the right messenger(s)◦ Work with the media◦ Make in-person presentations

Increasing Likelihood of Implementation◦ Include people with authority to effect change◦ Conduct advocacy with legislators and elected officials◦ Implement a separate Community Action Team (CAT)◦ Develop memoranda of understanding regarding next steps

Implementation of Recommendations: Literature Review and Site Visit Findings

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Results of Fatality Review Team Recommendations: Findings from the Review of Reports Many fatality review team reports did not

discuss the accomplishments of the team

A majority of reports did not link their accomplishments to specific recommendations

Public awareness was the primary achievement reported

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Many of the deaths share similar risk factors Many of the issues need to be addressed by

multiple systems Overlapping recommendations for prevention Identify strategies for working together Efficient use of resources Enhance the effectiveness Enhanced outcomes

Collaboration Among Review Teams, Child Welfare Agencies, and Other Social Service Agencies: Why?

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How many different types of child fatality and related reviews are being done in your State/community?

Has your State/community conducted an assessment of the multiple reviews? ◦ What are some of the reasons you might want to conduct an assessment?◦ What would it take to develop a plan for assessing these reviews? ◦ What would be the overriding objective? ◦ How would you justify the time and resources?

How can you maximize what is learned from the various reviews?

How could these reviews help child welfare?

What role does child welfare play in these reviews?

Small Group Discussion

Near Fatalities: A New Frontier?

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CAPTA defines near fatalities as:◦ an act that, as certified by a physician, places the child in serious or

critical condition. (106(b)(4))

In the child welfare context:◦ Several items in CAPTA refer to fatalities and near fatalities at the

same time, e.g. Must have provisions which allow for public disclosure of the findings

or information about the case of child abuse or neglect which has resulted in a child fatality or near fatality. (106(b)(2)(B)(x))

◦ Near fatalities refer to children rather than acts◦ Near fatalities are children who are in a specific condition

What is serious and critical?◦ Near fatalities depend upon a physician having found that the

child is in a serious or critical condition and reports to this to cps. CPS may determine that not a matter of child abuse or neglect.

Near Fatalities

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Traumatic Brain Injury (may lead to death and permanent injury; can be mild to severe/critical)◦ Nearly half a million ER visits for TBI by children 0-14◦ Very young 0-4 have highest rate of TBI related ER visits

(1,256 per 100,000) 474,000 ER visits; 35,000 hospitalizations; 2,174 deaths

◦ Males 0-4 have the highest rates of TBI related ER visits, hospitalizations, and deaths

◦ TBI caused by falls, motor vehicle injuries, struck by or against, assault, and unknown (21%); also firearms and sports related concussions

◦ 62% increase in fall related TBI seen in ERs for children 0-14, 2002 to 2006; rate of deaths decreasing

◦ Source: www.cdc.gov/TraumaticBrainInjury

Magnitude of the Problem

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Boys 10-14 high rates of TBI related firearm injuries

Children die of TBI resulting from lack of seat belts in traffic accidents; 25% of child deaths unrestrained◦ MMWR May 6, 2011 www.gov/mmwr/

We do not know how many children die of shaken baby syndrome or may suffer injury from being shaken. ◦ Boys are more likely to be injured than girls.

Magnitude continued

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Serious:◦ Vital signs unstable and abnormal◦ Acutely ill◦ Indicators are questionable◦ Likelihood of death less, but requires close supervision

Critical:◦ Vital signs are unstable and abnormal◦ Person may be unconscious◦ Indicators are unfavorable but death is not necessarily

imminent, can be stabilized and downgraded◦ Usually requires care in a intensive care unit

Both are related to status while in the hospital

Serious or Critical Condition

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The Elements of Classifying Near Fatalities

Near fatality

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HospitalTrain ICU and ER

doctors

Work with hospital administrators

Improving Data Collection

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Near fatalities may be an important intersection of work between CW and PH

Concerns are similar Access to information is with the medical

profession Response will be with the medical

profession and the child welfare profession New avenues for planning, coordination,

and collaboration?

Child Welfare and Public Health

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Do we have definitions of near death, beyond the CAPTA definition?

Have we engaged our local hospitals? Have we engaged the local chapters of the:

◦ American Association of Critical Care Nurses (500K) Do we understand enough about critical care?

◦ American College of Emergency Room Physicians (note often move from hospital to hospital)

◦ Society of Critical Care Medicine What are our objectives in addition to counting? Who are our most likely partners?

Small Group Discussion