Child Fatality Review Quick Reference: For Healthcare, Social Service, and Law Enforcement Professionals

Chapter 1

FATALITY REVIEW TEAMS

Robert W. Block, MD, FAAP

Theresa M. Covington, MPH

J.C. Upshaw Downs, MD, FASCP, FCAP, FAAFS

Mary Fran Ernst, F-ABMDI

Tricia D. Gardner, JD

Bill Harris, D-ABMDI

Deborah E. Lowen, MD, FAAP

Robert M. Reece, MD

Sara K. Rich, MPA

Child fatality review (CFR) is a collaborative process that brings together people from multiple disciplines at state or local levels to share and discuss information about the deaths of children and the response to those deaths.

The following are the goals of CFRs (Table 1-1):

—Tabulate and better identify the causes of death

—Promote better agency responses to protect at-risk children

—Develop child health and safety services, legislation, and policies

—Develop and promote prevention programs

—Develop product-safety actions

—Increase public awareness of child health and safety issues

Experienced CFR teams’ case reviews can identify risk factors, document findings, develop effective recommendations, and move recommendations to actions that promote child, adolescent, and family health and safety.

CORE COMPONENTS OF STATE AND LOCAL CHILD FATALITY REVIEW PROCEDURES

—Case review of deaths at review meetings

— Study of case review findings, recommendations, and actions to prevent deaths

— Management of the review program

— Models:

1.State and local model

2.State model

3.Local model

STATE AND LOCAL MODEL

— State agencies provide oversight and coordinate a network of local review teams.

— Reviews are usually conducted at the local level.

— Prevention initiatives implemented at state and local levels.

— State provides protocols or guidelines for local reviews, with varying degrees of authority.

— The agency that coordinates local teams varies, but is most commonly the health department, social services department, or district attorney.

— The state advisory committee reviews the findings of local teams and makes recommendations for improvements to state policies and practices.

— The committee produces an annual report with mortality data, CFR findings, and recommendations.

— The state rarely funds local teams.

— Most local coordinators and team members participate in the CFR as part of regular agency duties.

— The state CFR coordinator provides training and technical assistance to local team members. Some states have strict requirements that guide local team operations; other states allow local direction.

STATE MODEL

— The state-level CFR committee reviews child fatality cases and issues a state-level report of findings.

— It usually involves state agency representatives.

— With few exceptions, state committees review only a representative sample of all deaths.

LOCAL MODEL

Teams operate independently of the state, although a state-level person may help to coordinate training, give technical assistance to local teams, or both.

GOALS OF CHILD FATALITY REVIEW TEAMS

— Prevent child fatalities and injuries

— Increase awareness of familial genetic diseases

— Accelerate progress in understanding sudden infant death syndrome (SIDS)

— Reduce number of missed cases of fatal child abuse or neglect

— Focus attention on public health threats

— Identify problems of inadequate medical care

CASE REVIEW TEAM AND REVIEW PROCESS

— Members of CFR teams share agency information on specific circumstances leading up to and including fatalities and discuss agency responses to these deaths, including investigations and the provision of services.

— Teams try to identify risk factors in fatalities to prevent other deaths and uncover trends and patterns.

TEAM MEMBERSHIP

— All well-functioning teams require core members representing the office of the medical examiner/coroner (ME/C), child protective services (CPS), law enforcement, pediatrics, and prosecuting attorney’s office.

— Possible health care providers include family physicians; emergency department physicians; advanced-practice nurses; public health nurses; neonatologists; first responders such as emergency medical technicians and paramedics; health department staff; and child abuse specialists.

— Team members usually meet the following criteria:

1.Broadly represent community or state agencies responsible for protecting health and welfare of children

2.Broadly represent populations most at risk and affected by child fatalities

3.Willing to be open, honest, and cooperative

4.Willing to advocate or work directly for change to prevent child fatalities

5.Usually required to participate by legislation or policy, have jurisdictional responsibility to respond to child fatalities, and/or are appropriately positioned to help obtain support for suggested recommendations

6.Vary in size (Table 1-2).

7.May invite individuals with particular expertise for specific reviews or to brief team members on the subject of their expertise

8.Ad hoc members can include people directly involved with children or death incidents or investigations.

Law Enforcement Personnel

— Investigate children’s deaths, often along with ME/C.

— Contribute knowledge of the following:

1.Case status

2.Criminal histories of family members and suspects

3.Death scene investigations and interrogations

4.Evidence-collection processes

5.Access to and information from other law enforcement agencies

Child Protective Services

— Investigate allegations of child abuse or neglect and recommend or provide services.

— Serve as a liaison to broader child welfare agency and many community services.

— Contribute knowledge of the following:

1.Case status and investigation summaries for deaths

2.Family and child histories and socioeconomic factors that might influence family dynamics (eg, unemployment, divorce, previous deaths, history of intimate partner violence, history of substance abuse, previous abuse of children)

3.Previous reports of neglect or abuse in care of alleged perpetrator and the disposition of those reports

4.Designs for better interventions and prevention strategies and ways to integrate these strategies into system

5.Local and state issues related to preventable deaths

Prosecutor/District Attorney

— Prosecute children’s deaths when criminal acts are involved

— May be involved in dependency or juvenile proceedings for surviving children

— Legally define by the cases they take to trial and what the standards of acceptable practices regarding child safety are in their community

— Contribute knowledge of the following:

1.Case status

2.Previous criminal prosecution of family members or suspects in child fatalities

3.When cases can or cannot be prosecuted criminally

4.When cases may be pursued in juvenile court

5.Decision-making process around plea agreements in child fatality cases

6.Legal terminology, concepts, and practices

Medical Examiner/Coroner

— Definition of terms medical examiner (ME) and coroner vary by state.

— ME. An ME is an American Board of Pathology–certified forensic pathologist performing this same function.

— Coroner. A coroner is a person, almost always an elected official, who is not a forensic pathologist, who usually has no medical expertise, and who is charged with running the death investigation system at the local or county level.

— Coroner’s pathologist. A coroner’s pathologist is a hired physician, preferably, although not necessarily, an anatomic pathologist who performs autopsies on a contract basis for the elected coroner.

Professional Background of the Medical Examiner/Coroner

— As the intersection of investigative, legal, medical, and community interests, the coroner must be multitalented yet not overly focused on any one area. Each background brings potential strengths and weaknesses to the position.

— There are no specific requirements for a coroner to be a physician or even trained in a related field; the coroner system has operated for more than a millennium without much fundamental change from the single requirement that the coroner be a local citizen in good standing.

— Funeral-home directors are still probably one of the most common backgrounds, although retired law enforcement officers and physicians also serve as coroners. A funeral-home director understands postmortem findings and autopsy procedures, in addition to being well-versed in grief counseling for the family and community, but he or she might be construed as having a real or potential conflict of interest regarding bodies whose survivors may or may not use the services of his or her business.

— Retired law enforcement officers should bring strong investigative skills into play but need to be cautious not to become overly involved and attempt to supplant the police.

— Medical practitioners are more at ease understanding the intricacies of the medical findings during the autopsy and should be very familiar with local hospital customs and practices. They can thus facilitate the death investigation team’s access to certain tests and records as needed.

— Recently, ancillary medical personnel have begun to serve as coroners. People with these backgrounds must not extend activities into the practice of forensic pathology.

— The community should be aware of potential problems of having a nonprofessional death scene investigator; assuming death investigation expertise of nonprofessionals, even those with medical backgrounds, can irreparably damage case investigation. Arguments regarding (but not limited to) body transportation issues, evidence, and competence can be anticipated with any nonprofessional death investigator.

— If there is truly a need for field examinations to be performed, only an ME should conduct them.

— Ideally, a body should be competently secured at the death scene and transported directly to the ME’s office. Anything less, with rare exceptions, potentially constitutes malpractice.

— Very little, if any, formal education in death investigation is offered in US medical schools.

— Medical education is not necessarily relevant to duties of the office of coroner, provided that the coroner makes use of board-certified forensic pathologists to conduct examinations of the deceased.

Qualifications

— In our litigious society, some jurisdictions have introduced education on death investigation.

— Although not considered equivalent to years of formal medical education, courses may last a week and cover rudiments of postmortem change and working of local investigative system(s) to ensure a body receives an examination from a competent forensic pathologist.

— Other training sessions serve as introductions to various disciplines involved in modern forensic work.

— Specialized certification by entities such as the American Board of Medicolegal Death Investigators requires successful completion of courses and certification examinations.

Role

— Contribute knowledge of the following:

1.Status and results of office’s investigations into child fatalities

2.Autopsy reports and records reviewed by office for deaths

3.Elements and procedures followed by office investigating children’s deaths

4.Specific information about nature of injuries

5.Medical issues, including child injuries and child fatalities, medical terminology, concepts, and practices

6.Records accessed during investigations

Lay Death Investigators

— Employed by ME/C offices

— Investigate all deaths reported to office

— Conduct death scene investigations

— Gather critical data that assist in determining cause and manner of deaths

— Are a response to severe shortage of American Board of Pathology–certified forensic pathologists

1.Very few certified postsecondary institutions have associate’s degree programs available to people interested in becoming medicolegal death investigators.

— National Guidelines for Scene Investigators defines 29 essential tasks required to perform thorough death investigations. Publication is now titled Death Investigation: A Guide for the Scene Investigator.

— American Board of Medicolegal Death Investigators:

1.Purpose. Certification board to promote the highest standards of practice for medicolegal death investigators.

2.Designed to meet the public’s and forensic scientists’ need to identify professional, qualified medicolegal death investigators and the courts’ need to evaluate the competence of individuals.

— Expected to have proficient investigative techniques, communication skills, and medical knowledge, plus have additional training related to handling of the dead

— Medicolegal jurisdictions usually employ individuals with training and educational backgrounds in medicine, social and forensic sciences, law, mortuary science, and law enforcement to be investigators

Public Health Personnel

— Develop and implement public health activities to prevent injuries and deaths and for conducting health surveillance activities important to CFR

— All have maternal and child health as core agency functions

— Responsible for programs that improve health and safety of pregnant women, infants, and children; for monitoring infectious diseases in the community; and for providing information from neighborhoods and families, public health clinics, and home visits

— Contribute knowledge of the following:

1.Contacts made between families and public health agencies

2.Birth and death certificates

3.Statistical data

4.Epidemiological and health surveillance data

5.Programs for high-risk families

6.Development and implementation of public child death prevention activities and programs

7.Data collection and analysis

Pediatric and Family Health Professionals

— Offer expertise in health and medical matters concerning children

— Contribute knowledge of the following:

1.Services provided to children or families if seen by health practitioners

2.General health issues, including child injuries and deaths, medical terminology, concepts, and medical and parenting practices

3.Expert opinions on medical evidence

4.Injuries, SIDS, child abuse and neglect, and childhood diseases

5.Medical records from hospitals and other medical care providers

Emergency Medical Services

— Often first to arrive on scene when children die or are seriously injured

— Contribute knowledge of the following:

1.Emergency medical services (EMS) run reports

2.Details of scene, including people there

3.Medical information related to emergency procedures performed

4.EMS procedures/protocols

Additional Team Members

— Attorneys for CPS. If the actions taken to protect other children include removing surviving children from homes or terminating parental rights,

the process is shortened if CPS attorneys can hear information firsthand. CPS attorneys also provide legal information to teams, especially about process of child welfare court proceedings. The CPS attorney may be a local prosecutor.

— Childcare licensing investigators. Childcare licensing investigators are professional staff charged with investigating injuries and deaths in childcare facilities and home childcare as part of the licensing system. They provide information on specific cases and assist with understanding of systems issues affecting children.

— Intimate partner violence (IPV) program expert. Children are at increased risk for injury or death in homes where there is IPV. Participation of IPV program personnel may enable teams to further research links between IPV and child abuse, identify children at risk of injury, and improve communication between the IPV system and child welfare system.

— Education representatives. Education representatives provide school information about deceased children and siblings. They serve as conduits for prevention activities fostered in schools or with school-aged children. Included activities are suicide prevention, graduated driver’s license, and driver-education programs. Increasing communication between the educational system and child welfare system is another role of the education representation.

— Fire department representatives. Fire department representatives provide expertise on investigations of fire-related deaths and prevention efforts related to those deaths.

— Juvenile justice experts. Juvenile justice experts provide programs for victims and are responsible for oversight of juvenile perpetrators. They are linked with judges, referees, attorneys, probation and parole officers, and social workers who may have information relevant to teams. Juvenile justice experts may offer investigation information about cases involving juveniles in state custody.

— Local hospital representatives. Representatives of local hospitals may have medical records on children’s conditions and treatments. They can help access records, educate first responders and other team members on medical issues and hospital practices, and facilitate team efforts to improve hospital practices.

— Mental health professionals. Mental health professionals interpret results of psychological examinations for teams, provide information on family histories of mental health treatment, facilitate access to such information, and help assess current need for mental health care. They also provide information on grief counseling and trauma and assist with debriefing CFR team after deaths.

— Child abuse prevention organization participants. Participants in child abuse prevention organizations promote awareness, provide education, and mobilize community resources to prevent child abuse and neglect. State chapters of Prevent Child Abuse America are especially active. Participants offer specific knowledge and expertise about local communities and may be key prevention partners.

— Private/nonprofit community group representatives. Private/nonprofit community group representatives are effective in developing and implementing successful prevention programs. They also marshal community support and interest, including advocating for increased funding.

— Court-Appointed Special Advocates. Court-Appointed Special Advocates legally represent interests of children in court and may have information pertinent to teams. Because of unique legal and often personal relationships with children, their participation may raise special issues of confidentiality and disclosure (see later