Applying Lessons Learned from Child Fatality Reviews to Preventing Fatalities and Near Fatalities

1. 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.

2. Study Overview • 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

3. Study Products • 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

4. 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)

5. Child Maltreatment Fatalities, 2011 • 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.

6. Fatality Review Structures & Processes • The different types of reviews • Membership • Governance and structure • Case information and data • Shared perspectives

7. Fatality Reviews • 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

8. The Web of Reviews • Military Child Fatality Review • Internal Child Welfare Agency Review Maternal Mortality Review • Regional Child Fatality Review • State Child Fatality Review • Local Child Fatality Review • Citizen Review Panel • Child Fatality • Fetal & Infant Mortality Review Elder Death Review • Domestic Violence Fatality Review • Military Domestic Violence Fatality Review

9. 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

10. 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

11. 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.

12. 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

13. Prevalence and Types of Recommendations: Review of Reports • No mention of collaboration to enhance injury prevention • CDR and FIMR teams made recommendations regarding SIDS • 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

14. 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

15. Implementation of Recommendations: Literature Review and Site Visit Findings • 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

16. 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

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

18. Small Group Discussion • 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?

19. Near Fatalities: A New Frontier?

20. Near Fatalities • 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.

21. Magnitude of the Problem • 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

22. Magnitude continued • 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.

23. Serious or Critical Condition • 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

24. The Elements of Classifying Near Fatalities

25. Improving Data Collection

26. Child Welfare and Public Health • 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?

27. Small Group Discussion • 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?