1. Child Fatality Review Michael Durfee, MD, FAAP 1

2. Learning Objectives The participant will be able to: Explain the components and processes of effective child fatality review teams. Compare the relative benefits of active case review versus retrospective case review. Consider how child fatality review might be implemented in the host country given the level of resources and interagency coordination. 2

3. Case Discussion: Maria Mother takes 6-month-old Maria to the hospital in a coma, dilated pupils, weak pulse…she dies in minutes Mother states she tripped /dropped the baby on dirt Small bump on head, no other injuries Social Services: previous cases - parents use drugs and fail to supervise, older children malnourished Police: father arrested twice for beating mother 3

4. Case Discussion: Maria Could this be an accident or a homicide? What more would you want to know? Who might know what you want to know? Maria’s information could be in multiple agencies and in multiple jurisdiction. How would you collect it? 4

5. Outline Local procedures for handling child deaths History of response to fatal child abuse Child Fatality Review Team Structure: members, duties, reports Process: case review, data collection / analysis Action after review Prevention programs 5

6. Nations with no child death review: Add a contact to ask teams in other nations for help Read material on child death review Begin a practice and if possible ongoing review Nations that have child death review: Add new records to collect and analyze Connect with neighbors and help them start a team Add new components, e.g., child grief support Specific Goals 6

7. What is Child Fatality Review? The mission of child fatality review is to bring together information and resources to improve the management and prevention of child death. This mission is achieved through: Multidisciplinary teams that meet regularly to review child deaths collect data and learn to work together. Being inclusive : good teams include a wide range of agencies and a wide range of cases to review Some child deaths do not become suspicious until reviewed by the team 7

8. What is Child Fatality Review? Intervention PreventionSanction 8

9. History of Child Fatality: Denial, then Increasing Interest 1860: Dr Ambrose Tardieu, describes fatal child abuse Ignored for a century, then Kempe, Battered Child 1962 Multiple nations/jurisdictions are building teams 1978 - Los Angeles County, 2001 - all states 1990s - Canada and Australia, 2002 - New Zealand, 2012 – teams in approximately 13 countries Similar types of teams also created: Fetal Infant Mortality Review, FIMR Domestic Violence Fatality Review, DVFR -1990s Elder Abuse Fatality Review, EAFR 2000 9

10. History of Fatality Review Ancient Maternal Mortality –In 1700’s started to be evaluated New in recent years Fetal Infant Mortality Review – 1980s Domestic Violence Fatality Review -1990s Elder Abuse Fatality Review - 2000- Future Nonfatal/Severe Injury review Mix child and domestic violence deaths (MDT) More nations with fatality review teams 10

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12. Team Structure and Sharing Records Membership Coroner or equivalent Medical experts in pediatrics and child maltreatment. Mental health, health and public health Police, prosecutor, social services, Clergy and others of local interest. Confidentiality Agency records not shared outside room Getting started Start with 1-3 cases, notify agencies so they can collect records 12

13. How to Review Cases 1.Each agency brings the case information for child new reviews or follow up on previous deaths. 2.Any agency can start. Discuss one case at a time with all agencies sharing what they know. 3.Record basic case data for annual report on types of cases reviewed and basic outcome. 4.If an agency wants to pursue information outside of the team they should make a contact after the meeting to gather it outside of the team. 13

14. How to Review Cases 4.After each agency presents their information: a)Allow for brief questions to clarify the interpretation of certain facts b)List questions/issues that are not answered and assess what might resolve that issue. c)Each agency is responsible to participate but retains their separate authority over their work. 14

15. How to Review Cases 4.After each new case review: e)Create a “to-do” list for team members to follow-up and report on during the next meeting 5.Old cases: follow-up and new action items a)Follow up on assignments or new information b)The peer group can keep the team accountable 15

16. Collect data Each agency should provide at least one datum: Basic information: child’s age, gender, address Hospital – medical illnesses – past and present Coroner – Cause and manner of death Law enforcement – possible suspect, past arrests Prosecutor – court action, if any Social services –records on siblings, or risk factors Other agencies 16

17. When to review cases? Depends on your goals Active case review: as soon as possible or weekly Helps investigation, case management, court action Maximizes team process and quality control Serves siblings and other survivors Intervention with siblings should not wait Trends can be summarized, which aids prevention Retrospective case review: after months or end of year Does not review the facts of each death Summary of long trends, which may aid prevention Less challenge to agency action 17

18. 18 Homicides in U.S. (2000)

19. Analyze Data and Support Prevention Programs Write an annual report and share it with the public Support local programs for identified problems. Accidental Injury Prevention Drowning, bicycle safety, traffic safety, fire safety Family and community can be involved in prevention Major prevention campaigns Safe sleeping practices – ie. “Back to Sleep” “Safe Haven Program” – voluntary surrender custody 19

20. Analyze Data and Support Prevention Programs Suicide Prevention Outreach to schools, public education Promote health, safety and mental health services Homicide by caretaker Friends, family neighbors – encourage involvement Health systems – connect to your team Child protective services to increase connections Joint case management with other agencies More participation from the community 20

21. Helping the Surviving Family Provide safety, information, support, continuity Participation in funerals, grave visits and memorabilia Team follow up on sibling and other survivors Agency training on child interview on death Referral resources for survivors Define programs that can serve all survivors the very young and different language and culture Professional casualties including support by agencies 21

22. Resources Contact other teams in your region Teams can support themselves and each other Education: give presentations on specific topics in your field to the other members of your team Knowledge in child development and family interaction is important for all team members Major resources National Associations and Federal Programs Other teams to share resources and cases 22

23. www.ICAN4kids.org Grief and Mourning Videos Team Reports Statewide hospital network History / International links Curriculum -child death, nonfatal/severe At a Glance short overview and short report model 23

24. www.childdeathreview.org/ Calendar of event “How to” manual Data model Prevention programs State spotlights Contacts for U.S. state teams 24

25. Additional Internet Resources U.S. Center for Disease Control, Federal Health Sudden Unexplained Infant Death Investigation WISQARS, CDC WONDER – Injury data Pubmed - medical literature ISPCAN, WHO, UNICEF– International Efforts Ray Helfer Society – pediatric experts National Domestic Violence Fatality Review Sites for public health, criminal justice 25

26. Potential Benefits Cases may be better managed by the team Agencies learn to work together Agencies learn about families and young children Agency quality control from other agencies The multiagency team working with the total community provides a prevention forum Services and support for survivors of violent death including fatal family violence 26

27. Future of Child Fatality Review International directory and more teams across the world Combine fatality review with all other forms of child maltreatment and domestic violence case review Multi-jurisdictional and multinational case review Grief support for family and front-line workers Computerized data for all agencies Increase the number and size of prevention programs 27

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29. Terms Used in Child Fatality Review Cause of death = the medical explanation of the death Injury, infection, cancer, toxin, heat or cold, malnutrition Manner of death = Intent, including self versus others E.G., acute gun shot wound: Suicide - Intent to kill or injure self Homicide - Intent to kill or injure another another Accident or non-intentional - No intent Undetermined manner - Unclear intent Undetermined cause - Unclear why death occurred 29

30. Terms Used in Child Fatality Review Sudden Unexpected Infant Death (SUID) A general category of infants who die rapidly without warning by illness of different cause/manner Sudden Infant Death Syndrome (SIDS) A specific diagnosis, only after excluding other possible causes with complete investigation and autopsy. Undetermined Cause and/or Manner Cases that are not clear after investigation Team review may help with clarity 30

31. Potential problem terms Intent– it may be hard/impossible to determine Confounding event – e.g. co-sleeping infant death could be Homicide, Accident, or Natural and may be called undetermined Investigation – may be detailed or superficial with gaps between agencies and missing past records 31