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Child Fatality Prevention System

The Colorado Child Fatality Prevention System (CFPS) is a multi-disciplinary, multi-agency team that makes prevention recommendations based on child fatality data in Colorado.

Child Fatality Review (CFR) teams conduct systematic, comprehensive, multidisciplinary reviews of all preventable childhood deaths to better understand how and why children die. Using a public health approach, CFR teams examine the trends and patterns of child deaths in order to make population-based recommendations to prevent future deaths and improve the health and safety of children. This public health review process is different from department of human service child fatality reviews, which focus only on child abuse and neglect cases known to the county human service system.

Each year, the state of Colorado sees nearly 700 fatalities among children under the age of 18. Of these child fatalities, about half are the result of natural causes among infants that occur in the neonatal period (the first 28 days of life). These neonatal deaths do not have clear preventability and therefore, they are not generally included in the CFR process. Currently, the Colorado Department of Public Health and Environment (CDPHE) CFPS staff reviews the death certificates for the remaining 350 child fatalities each year to determine which child fatalities have clear preventability resulting in comprehensive, multidisciplinary reviews conducted by the CFPS State Review Team on about 200 preventable child fatalities per year. The following causes of child fatality are reviewed:
• Undetermined causes
• Unintentional injury (e.g. drowning, falls, fires)
• Violence (e.g., homicide, any firearm death)
• Motor vehicle incidents
• Child abuse and neglect
• Sudden unexpected infant death (SUID)
• Suicide


Colorado CFPS Collaboration Website:


Colorado Child Fatality Prevention System


  • The Colorado Department of Public Health and Environment has conducted child fatality reviews at the state level since 1989.
  • The Child Fatality Prevention System (CFPS) was codified in statue in 2005 and housed at CDPHE in the Prevention Services Division’s Injury, Suicide and Violence Prevention Branch. The statue did not receive an appropriation until SB255 passed during the 2013 legislative session. 
  • The 2005 statue required the State CFR Team to review all preventable fatalities of children ages 0-17 that occur in the state of Colorado. This public health review process is different from human service fatality reviews, which focus only on child abuse and neglect cases known to the county human service system. Public health reviews are conducted to identify trends across a variety of child fatality causes and make prevention recommendations for the future.
  • The 2005 legislation allowed local teams to form but did not require them. Currently, there are only four local teams that are actively functioning (Denver, Morgan, Jefferson, and Mesa). A few other counties/regions had local teams in the past (e.g. Pueblo and El Paso), but have not been active in recent years.
  • The 2013 update to the CFR legislation requires that all local public health agencies operate a local child fatality review process. Locals can choose to regionalize the CRF teams. All teams must be operational by January of 2015.
  • In 2009, the State CFR Team began using the National Center for Child Death Review’s Web-Based Data Collection System. This system currently contains complete data on child deaths reviewed from 2004-2011. The State CFR Team is now in the process of reviewing and entering cases from 2012 and 2013.

With the 2013 passage of Senate Bill 255, all comprehensive reviews will shift from the State Review Team to the local level. This statute requires local public health agencies to establish or arrange for the establishment of a local, multidisciplinary child fatality review team. CDPHE will provide oversight, funding, and comprehensive technical assistance to local (or regional) child fatality review teams. The full  CFPS Colorado Revised Statute pdf file  authorizing the Child Fatality Prevention System has been updated to include SB 13-255 changes.


The CFPS Team at CDPHE created an 18-month timeline for implementation of Senate Bill 255 and shifting reviews to local public health. Please review the  Child Fatality Implementation Timeline pdf file to learn more about the implementation process.

Local public health agencies are required to establish or arrange for the establishment of local, multidisciplinary child fatality review teams. Local public health agencies may choose to structure the teams as single-county teams or as multi-county, regional teams.  Local public health agencies may designate another lead agency to facilitate the CFR process for a single-county or for all counties on a regional team. All local review teams must be formed and operational by January 1, 2015.

CDPHE CFPS support staff is available to consult or provide technical assistance to help local teams form. Please contact CFPS staff
to ask for more information.

The CFPS support staff facilitated regional meetings in October and November 2013 to educate local communities about the child fatality review process. To learn more about the local child fatality review process, watch the recorded Child Fatality Regional Presentation.
Local Team Duties
According to Colorado Revised Statute 25-20.5-405, local CFR teams are responsible for the following list of duties:

• Access death certificate information for fatalities that that occur in each local team jurisdiction. CDPHE CFPS support staff will identify child fatalities and will provide death certificate information to local team coordinators via secured case assignment folders. At a minimum, local teams will review the following causes of child fatality:

  • Undetermined causes
  • Unintentional injury (e.g. drowning, falls, fires)
  • Violence (e.g. homicide, any firearm death)
  • Motor vehicle incidents
  • Child abuse or neglect
  • Sudden unexpected infant death
  • Suicide

• Local teams may choose to review other types of deaths (e.g. cancer, other medical cause deaths), but they will not be required to enter this case information into the data collection website.

• The number of cases each local CFR team will be responsible for reviewing depends on the number of child fatalities that occur in its jurisdiction each year. It is possible that some local teams will not have cases to review every year. Generally, the larger the population in the local team jurisdiction, the more cases the local team will need to review.

• Gather case records from a variety of sources, including law enforcement, coroner records, hospital records and human service records. Local teams may choose to request case records ahead of time or they may ask members of the CFR team to bring records with them to team meetings.

• Conduct case-specific, multidisciplinary reviews of all child fatalities (ages 0-17) that occurred in the jurisdiction of the local review team. The focus of each review is to use the comprehensive information collected about each child fatality to identify risk factors and prevention opportunities in a systematic way.

• Enter data into the data collection website (National Center for Child Death Review Case Reporting System) to report case findings and to identify recommendations for improvement to local policies and practices. The focus of each review is on the prevention of child fatalities.
Local Team Membership
According to Colorado Revised Statute 25-20.5-404, at minimum, local CFR teams must include representatives from the following agencies located within the jurisdiction of the local team:

• Each county department of human services
• Local law enforcement agencies
• District attorney’s office
• School districts
• Each county department of public health
• Each coroner’s office or county medical examiner’s office
• Each county attorney’s office

A local team may also include representatives from the following agencies:
• Hospitals, trauma centers, or other providers of emergency medical services
• Each county board of social services
• Mental health professionals
• Medical professionals specializing in pediatrics
• Each court-appointed special advocate program
• Child advocacy centers
• Private out-of-home placement providers
• Victim advocated associated with law enforcement agencies
• The community at large

State Team Membership

The Child Fatality Prevention Act (Colorado Revised Statute 25-20.5-401-409) created the Colorado Child Fatality Prevention State Review Team (State Review Team). The State Review Team is comprised of forty-six members representing multiple disciplines and agencies, explicitly described in the legislation, and shall be appointed for three-year terms. The State Review Team includes:
• Eighteen (18) voting members appointed by the Governor,
• Sixteen (16) voting members who represent state agencies (CDPHE, Department of Human Services, Colorado Department of Public Safety and Colorado Department of Education) appointed by the executive directors, and
• Twelve (12) additional non-voting members selected by majority vote of the Team.

Currently, the State Review Team is a volunteer multidisciplinary committee comprised of clinical and legal experts in child health and safety that work collaboratively with CFPS support staff to review deaths of children under the age of 18. Members of the State Review Team are experts in the fields of child abuse prevention, pediatrics, family law, death investigation, motor vehicle safety, and sudden infant death syndrome (SIDS)/sudden unexpected infant death (SUID).

State Team Duties

According to Colorado Revised Statute 25-20.5-407, the State Review Team and CFPS support staff are responsible for the following list of duties:
• The State Review Team will provide protocols and guidelines for local CFR teams.
• The State Review Team will provide training and technical assistance to all local review teams regarding the facilitation of a CFR process, confidentiality, data collection, evidence-based prevention strategies, and the development of prevention recommendations.
• The State Review Team will aggregate data from all of the local review teams to identify state-level trends and patterns of child fatality and will make state-level policy and systems prevention recommendations.
• The State Review Team will provide annual data reports to each local review team that summarizes its local/regional data entered into the data collection website.
• The State Review Team will work with the Colorado Department of Human Services Child Fatality Review Team to issue joint prevention recommendations for child abuse and neglect fatalities.
• The State Review Team will generate an annual legislative report to the Colorado State Legislature each July. The report will include recommendations for preventive actions and policy improvements to promote the safety and well being of children that are based on the aggregated data from the local team reviews.


Resources for Colorado Child Fatality Review Teams

National Resources for Child Fatality Review Teams

Colleen Kapsimalis, MPH, CPH

Child Fatality Prevention System Program Manager

(303) 692-2388