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)
Colorado CFPS Collaboration Website:
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 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 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:
• 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:
State Team Duties
Resources for Colorado Child Fatality Review Teams
National Resources for Child Fatality Review Teams
Colleen Kapsimalis, MPH, CPH
Child Fatality Prevention System Program Manager