Fatality Review Department of the Army Update 11 August 2009 Mr. Richard F. Stagliano

1. Fatality Review Department of the Army Update 11 August 2009 Mr. Richard F. Stagliano Family Programs MWR For All Of Your Life

2. P.L. 108-136, Sec. 576 Each fatality (implicitly includes suicides) Known or suspected to have resulted from domestic violence or child abuse against any of the following: A member of the Army on active duty A current or former dependent of a member of the Army on active duty A current or former intimate partner who has a child in common or has shared a common domicile with a member of the Army on active duty Fatality Review

3. Fatality reviews are a critical part of the effort to formulate lessons learned and identify trends and patterns that assist in developing policy recommendations for early/effective intervention Garrison Commanders or their designees have responsibility for conducting fatality reviews (dv, can and suicide related to an act of dv or can), approving and forwarding an annual report through IMCOM to FMWRC – Suspense: 1 May 10 Installation reports are due 24 months following the end of the fiscal year in which fatalities occurred Objectives

4. An executive summary on each fatality Victim demographics, injuries, autopsy findings, homicides or suicide methods, weapons, offender demographics, household information and intervention timelines SJA verified legal disposition involving homicides and conducted a sufficiency review System interventions and failures Analysis of significant findings Recommendations for systemic changes Services provided to surviving Soldier/Family members Signed by Garrison Commander Annual Report Requirements

5. Chair, Garrison Commander or designee Meets quarterly Multidisciplinary and impartial Members – Core Additional Members Chief, SWS/CRC Chairperson Dental Activity Commander FAPM (coordinator) Public Health Nurse Pediatrician/Family Practice Chaplain Medical Examiner/Pathologist CYS Coordinator Staff Judge Advocate PAO ASAP Clinical Director Consultants Command Sergeant Major School Counselor Provost Marshal Child Protective Services CID Local court administrator NPSP/EFMP Fatality Review Committee (FRC)

6. ACR and COPS databases Request information early Preliminary data from Army Records Center indicated a significant number of cases met the death investigation criteria for fatality review but were not reviewed by local FRCs Autopsy Report (summary section)/Final CID Report Summary Used to complete the EXSUM – Spells out the Who, What, Where, When, Why and How regarding the fatality Used to construct the intervention timelines Note: Explain if there are differences between information contained in these or other documents Sources of Information

7. The decedent was a two month old dependent son African-American) of a 21 yr old female PFC assigned to Fort ____ with her 22 yr old dependent husband (African American). The Family lived off post. On 8 Apr 06, the infant was taken to MTF via ambulance with no respiration. The civilian father reported to EMS that while feeding the infant, he became apneic, turning blue on the lips. The infant was life-flighted to MEDCEN for further care. The infant received a full non-accidental trauma exam which revealed further injuries to include brain injury, retinal damage to both eyes and died as a result of his injuries. Medical personnel at MEDCEN stated that the injuries were consistent with Shaken Baby Syndrome. The child died on 17 Apr 06. A joint investigation was conducted between CID and the local police. The mother and father were charged with murder. The mother was charged with 1st degree criminal abuse and murder because she allowed her husband to watch her child even though she had an active protection order against him for domestic violence. Case Summary - Child

8. The decedent was a 22 year old Active Army Specialist African-American) assigned to _____ with his civilian spouse (Caucasian) and three children. The Family lived off post. On 11 Dec 05, the 24 year old dependent wife admitted to stabbing and killing her husband. She stated the incident was due to an argument with her husband. It was reported that the Soldier overheard his wife on the phone with another man and an argument ensued. As the Soldier came towards his wife, she grabbed a kitchen knife off the counter and stabbed him once in the chest according to police. The Soldier was intoxicated at the time of the incident. The victim died on 11 Dec 05. The manner of death was homicide. The children were initially place in the care and custody of the _____ county Social Services Department and then in the care of the paternal grandmother. The children received counseling from a civilian provider. The Soldier was being treated for PTSD and conversion disorder. He was also participating in ASAP. There was FAP involvement due to DV. Multiple FAP providers were involved in the case. Although advocacy and counseling services were offered to the wife, she declined. The wife received a 10 year confinement sentence which was suspended; she was placed on probation for five years. Case Summary - DV

9. On 5 Nov 05, a retired Army SM (Hispanic), age 44, fatally injured his 36 year old Active Army SFC spouse (Caucasian) with a gunshot wound to the head. The husband committed suicide with a self-inflicted gunshot to the head. The weapon was owned by the husband. The Family lived off post. The homicide/suicide was witnessed by the couples 13 year old daughter. The daughter contacted 911 and prevented her 8 year old sister from viewing the crime scene. The AD spouse redeployed from Iraq, completed block leave prior to the homicide. The AD spouse had petitioned for divorce (19 yr marriage) precipitated by spousal’s infidelity. The husband would be granted the home, the AD spouse would be granted custody of the children. The incident occurred while the AD spouse was relocating. The autopsy findings reported the husband’s blood alcohol was negligible (wine). The command and neighbors reported no red flags for the couple. The victim had completed deployment to Iraq and block leave. The retired SGM participated in approximately 4 deployments prior to retirement. The daughters were provided counseling following the death of their parents and relocated to reside with the paternal grandparents in __________. Case Summary - H/S

10. Fatality Review – Allows the Army to identify systemic problems and formulate lessons learned ** Note: Army Criteria: Soldier deployed, re-deployed OIF/OEF within 6 months prior to fatality

11. 14 Child Abuse and Neglect Fatalities 4 (29%) victims were male; 10 (71%) were female 14 (100%) had more than one risk factor 8 (57%) were unknown to FAP 6 (43%) occurred while Soldier was deployed 10 (71%) involved substance abuse/behavioral health issues 11 (78%) were under the age of four; 8 (57%) < one 6 (43%) were neglect; 4 (29%) drowning; 1 (7%) starvation and 1 (7%) smoke inhalation 3 (22%) were accidental deaths, 9 (64%) homicides and 2 (14%) undetermined 4 (44%) offenders were fathers/step-fathers; 4 (44%) were mothers and 1 (12%) was a sibling 2 (14%) had known co-occurrence of domestic abuse 8 (57%) occurred on base; 6 (43%) off base FY07 CAN Fatalities

12. 10 Domestic Violence Fatalities 6 (60%) were suicides, 4 (40%) homicides 4 (40%) had a history of substance abuse 5 (50%) involved firearms 1 (10%) occurred within 6 mos of deployment/re-deployment 5 (50%) couples were separated as a result of severe marital discord 4 (40%) involved allegations of marital infidelity 4 (40%) occurred on base; 6 (60%) off base FY07 DV Fatalities

13. Paradigm Changes in Community Systems Data Gathering The Cycle of Improvement Community Action Case Review

14. Source: The National Center for Child Death Review State Profile Database: Reports from State CDR Program Coordinators, May 2009 State Agency that Leads Coordination of CDR Program

15. Source: The National Center for Child Death Review State Profile Database: Reports from State CDR Program Coordinators, May 2009 Types of Death Reviews by State CDR Teams

16. Source: Children’s Safety Network, United States Fact Sheet, 2008 Leading Causes and Total 5-Year Incidence of Injury Deaths by Age Group, The United States, 2000-2004

17. Source: Children’s Safety Network, United States Fact Sheet, 2008 Leading Causes and Total 5-Year Incidence of Injury Deaths by Age Group, The United States, 2000-2004

18. OSD stated that the Services can collect fatality review data as close to the death as possible, within the limits of the law Look out for suicides when there is volatility – guns in the home Marital discord is a predominate factor Divorce is a high stressor Threats of homicide and/or suicidal comments should be taken seriously and immediately reported to command and/or appropriate agencies DoD Fatality Review SummitFY06 Results

19. DV Gunshots were cited as the most common method of death by all Services 53% of the victims were active duty members Alleged offender factors – low marital satisfaction, conflict with partners, reported anger problems and separation from partner CAN Army and Navy cited blunt force trauma as the leading cause of death; Air Force cited asphyxiation Approximately half of offenders were active duty service members, and most were male OSD adopted 4 Army recommendations Recommendations need to be agency specific DoD Fatality Review Summit FY06 Results

20. DHHS agreed to collaborate with DoD in improving access to medical and law enforcement records or death review reports concerning deaths related to child abuse/neglect DoD will explore whether DOJ grants to states under the Violence Against Women Act could improve similar access to records concerning dv-related deaths Some child death investigations in the civilian community were more likely to be classified as SIDS because of inadequate law enforcement training DoD Fatality Review Summit FY06 Results

21. Initiate and support collaboration with other military and civilian agencies Conduct fatality reviews early Request data from ACR/CID Request law enforcement personnel’s assistance in collecting medical records/medical examiner’s information Utilize the FRC to construct timelines, analyze significant findings/systemic issues, track services to survivors and recommend solutions Complete specified Data Sheet(s) Keys to Success

22. Explain the reason(s) if the requested information in operational guidance cannot be provided Challenge accidental, SIDS or natural death initial findings Target high risk populations with effective prevention and education programs Obtain legal sufficiency review Ensure installation annual report is signed by the Garrison Commander and received by FMWRC by 1 May 10 Keys to Success

23. DA Domestic Violence and Child Abuse Fatality Review, Fourth Annual Report, FMWRC, September 2008 HQDA Operational Procedures, 5 Jun 08 Para 2d (1)–(7) through 2g Para 10, lessons learned OTSG/MEDCOM Policy Memo 08-033, 22 Jul 08, Mandatory Briefings on Shaken Baby Syndrome A Program Manual for Child Death Review, National Center for Child Death Review, www.childdeathreview.org Guides to Effective Child Death Reviews, The National MCH Center for Child Death Review The Status of Child Death Review in the United States in 2008, Updated May 2009, The National Center for Child Death Review State Profile Database OJJDP Fact Sheet, The National Center on Child Death Review, April 2001, # 12 References

24. CDC’s Violence Prevention Resources – www.cdc.gov/injury, call 1-800-CDC-INFO Home Fire Safety: Be Safe and Sound, Home Safety Council - www.homesafetycouncil.org Suicide Prevention Resource Center – www.sprc.org, 877-GET-SPRC (877-438-7772) Sudden Unexplained Death in Childhood Program – www.sudc.org, 1-800-620-SUDC Stop Bullying Now, Activities Guide – www.stopbullyingnow.hrsa.gov NFIMR Bulletin: A Publication of the National Fetal-Infant Mortality Review Program, Jan 2000, Fatal and Infant Mortality Review and Child Fatality Review: Opportunities for Local Collaboration Fact Sheet – www.childdeathreview.org, National Center for Child Death Review, 1-800-656-2434 Children’s Safety Network – www.ChildrensSafetyNetwork.org, National Injury and Violence Prevention Resource Center References Cont’d

25. Questions?

26. Back-up Slides

27. Laws, Directives, Instructions, and Regulations • PUBLIC LAW 97-291, VICTIM WITNESS PROTECTION ACT OF 1982 • DoD DIRECTIVE 1030.1, VICTIM AND WITNESS ASSISTANCE, 1984 • DoD DIRECTIVE 6400.1, FAMILY ADVOCACY PROGRAM, 2004 • DoD MANUAL 6400.1M, FAMILY ADVOCACY QUALITY ASSURANCE STANDARDS • DoD INSTRUCTION 6400.3, FAMILY ADVOCACY COMMAND ASSISTANCE TEAM • DoD INSTRUCTION 6400.06, DOMESTIC ABUSE INVOLVING DoD MILITARY AND CERTAIN AFFILIATED PERSONNEL, 2007 • PUBLIC LAW 103-160, NATIONAL DEFENSE AUTHORIZATION ACTS, 1994 • PUBLIC LAW 107-311, ARMED FORCES DOMESTIC SECURITY ACT, 2002 • ARMY REGULATION 608-18, FAMILY ADVOCACY PROGRAM, 2006 • ARMY REGULATION 608-1, ARMY COMMUNITY SERVICE, 2007

28. Child Abuse – The physical or mental injury, sexual abuse or exploitation, or negligent treatment of a child. It does not include discipline administered by a parent or legal guardian to his or her child provided it is reasonable in manner and moderate in degree and otherwise does not constitute cruelty. Domestic Violence – is an offense under the United States Code, the Uniform Code of Military Justice, or state law that involves the use, attempted use, or threatened use of force or violence against a person of the opposite sex, or a violation of a lawful order issued for the protection of a person of the opposite sex, who is (a) a current or former spouse; (b) a person with whom the abuser shares a child in common; or (c) a current or former intimate partner with whom the abuser shares or has shared a common domicile. DoD Definitions

29. Army Child Abuse Cases FY 2000-2008 Data from Army Central Registry, 6 Feb 09

30. Army Spouse Abuse CasesFY 2000-2008 Data from Army Central Registry, 6 Feb 09