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Fatality Review


During the 2011 Colorado legislative session, House Bill 1181 was passed which codified the Colorado Department of Human Services’ (CDHS) Child Fatality Review Team (CFRT) and provided statutory authority through the addition of section 26-1-139 of the Colorado Revised Statutes. The statute outlines the guidelines regarding the CFRT’s purpose, structure, and reporting procedures.
In 2012, statute was amended when Senate Bill 12-033 was passed, adding to the purview of the CFRT, the review and public disclosure of non-confidential information regarding egregious and near fatal incidents to the existing requirement of public disclosure of information regarding fatal incidents of child abuse and neglect. These changes allow the CFRT to gain a better understanding of the causes, trends, and system responses to child maltreatment and develop recommendations in policy, practice and systemic changes to improve the overall health, safety, and wellbeing of children in Colorado and mitigate future child fatalities.
Beginning August 1, 2012, Colorado county DHS agencies began reporting all egregious and near fatal incidents (in addition to the already required child fatalities) suspicious for abuse and neglect, within 24-hours of becoming aware of the incident. The Fatality Review Public Notification webpage was created as a means to provide “public disclosures of findings or information about a case of child abuse or neglect that resulted in a child fatality or near fatality” as required under the federal “Child Abuse Prevention and Treatment Reauthorization Act,” 42 U.S.C. § 5101 et seq. Public Notifications are posted within three business days of the CDHS receiving the information from the county DHS. Public Notification of an incident simply denotes maltreatment of a child is suspected, not confirmed.
After amendments were made to statute in 2012, the CFRT began reviewing egregious and near fatal incidents in addition to the reviews they were already completing on fatal incidents. Senate Bill 12-033 indicates cases are to be set for review within 30 days of receiving the necessary documentation from the county DHS agency, when the following things are true:
Ø The incident was substantiated for abuse or neglect.
Ø The child or family had ‘previous involvement’ with a county DHS agency that was directly related to the incident.
Ø The previous involvement with the DHS agency occurred within two years prior to the incident.
The definition for ‘previous involvement,’ as defined in Senate Bill 12-033 was, a situation, in which the county department received a referral, responded to a report, opened an assessment, provided services, or opened a case in the Colorado Trails system; except when:
1.      The situation did not involve abuse or neglect;
2.      The situation occurred when the parent was seventeen years of age or younger and before he or she was the parent of the deceased child;
3.      The situation occurred with a different family composition and a different alleged perpetrator.
In 2013, statute was further amended with the passage of Senate Bill 13-255. The bill removed the three aforementioned exemptions as they relate to previous involvement of a family with the county DHS agency. Additionally, the time frame of previous involvement the CFRT reviews was extended from two years to three years.    
Statute previously required the CFRT to complete a draft, confidential, case-specific review report following the CFRT review and submit the draft to any DHS agency with previous involvement with the child or family related to the incident within 30 days. That 30-day period was extended to 55 days.
Language was also added to statute to ensure that any information released to the public by the CFRT is “not explicitly in conflict with federal law, is not contrary to the best interests of the child who is the subject of the report, or his or her siblings, is in the public’s best interest, and is consistent with the Federal Child Abuse Prevention and Treatment Reauthorization Act of 2010, P.L. 111-320.”
Previous statute required the CDHS, on or before April 30, 2013, and each April 30th thereafter, to prepare an Annual Child Fatality and Near Fatality Review Report, absent confidential information, summarizing the reviews conducted by the team during the previous year. Senate Bill 13-255 amended the date to, on or before July 1, 2014, and on or before each July 1 thereafter. The CDHS was given the additional duty to make annual policy recommendations that address “all systems involved with children and to follow up on specific system recommendations from prior reports that address the strengths and weaknesses of child protection systems in Colorado” in the annual report. This report will be transmitted to the Governor, appropriate legislative committees, the Colorado State Child Fatality Prevention Review Team established in the Department of Public Health and Environment pursuant to section 25-20.5-406, C.R.S., and made available to the public on the Administrative Review Division, Public Notification webpage website within seven days of finalization of the report. 


 Links to additional information:                                                                                                                      

·         CFRT Process Timeline                                                                                                                                       

·        Colorado Revised Statutes (C.R.S. 26-1-139)                                                                                                                        

·         Volume VII (7.202.77- 7.202.8)                                                                                                                                           

·         Statutory Definitions 


Colorado Child Maltreatment

Fatality Review Reports




If you have any questions regarding the Colorado Child Fatality Review Team or
if you need to report an egregious incident, fatality or near fatality please
contact the Administrative Review Division @ 303.866.7160.