Child Death Review Teams

Background

Child death review teams date back to the late 1970s when Los Angeles, California; North Carolina; and Oregon created teams to better identify and respond to child fatalities related to abuse and neglect. For these communities and others, the awareness that the statistics they had available about child deaths offered little in the way of understanding the risk factors or circumstances that led to the death, or what could be done to [Page 102]prevent a death, prompted initiatives for improvement. In addition, the growing concern about the accuracy of SIDS findings led to an awareness of the need to understand how deaths were being investigated and whether services provided to children and families were adequately focused on child safety. The first review teams uncovered important indicators of maltreatment in cases that had been ruled as accidental or unintentional deaths. In 1990, a Missouri study concluded that child deaths due to maltreatment were grossly underreported and, as a result, this state became the first to enact a law requiring multidiscipli-nary review of child deaths involving children under the age of 15. Since that time, teams have developed in 50 states in the United States as well as nine Canadian provinces, parts of New Zealand, Australia, and South Africa. The scope of the reviews has broadened, from identifying and focusing on fatalities that are a result of maltreatment to understanding all causes of death and recommending improvements in all areas of child health and safety. Addressing system failures, particularly in abuse and neglect fatalities, is still a critical function of child death review teams.

Major Components of Child Death Reviews