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, child fatality review teams examine the trends and patterns of child deaths in order to make population-based recommendations to prevent other deaths and improve the health and safety of children. 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.
On average, there are approximately 700 child fatalities (ages 0-17) that occur in the state of Colorado. About half of these fatalities are from natural causes among infants under than 28 days and are generally not reviewed. Currently, the CDPHE Child Fatality Prevention System staff review the death certificates for the other 350 child fatalities a year. Comprehensive, multidisciplinary reviews are conducted by the State Review Team on about 200 preventable child fatalities per year.
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 may work together to establish regional review teams. Local public health agencies may designate another lead agency to facilitate the review process. All local review teams must form by January 1, 2015.
CDPHE 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 staff will facilitate regional meetings in October and November 2013 to educate local communities about the child fatality review process and conduct a mock local review team meeting which will demonstrate individual child fatality case reviews. This information will be helpful to local communities as they determine how best to form their local teams.
Though the Program Manual for Child Death Review is listed in the resource section, CDPHE CFPS staff is currently developing a Colorado-specific manual to guide local review teams through the child fatality review process. Guidance includes:
- Forming Teams;
- Case Selection;
- Records Requests;
- Case Abstraction;
- Conducting Case Review Meetings;
- Requesting Data Analysis Support from CDPHE;
- Secured Record Keeping;
- Generating Prevention Recommendations;
- Responding to the Media; and
- Program Evaluation.
Per recent legislative update, the following are a list of duties assigned to local review teams:
- At minimum local/regional teams must include representatives from the following agencies: local public health, county human services, local law enforcement agencies, district attorney’s office, school districts, county attorney's office and county coroner’s office. Representatives from other entities or groups can also be invited to participate in the local team.
- Local/regional teams will be responsible for conducting case-specific, multidisciplinary reviews of all child deaths (ages 0-17) that occurred in the jurisdiction of the local and regional review team. CDPHE will identify child deaths that occur in each local/regional team jurisdiction and provide death certificate information to team coordinators via a secure portal.
- The number of cases each local or regional team would be responsible for reviewing depends on the number of deaths that occur in that catchment area each year. It is possible that some local teams would not have cases to review every year. Generally, the larger the population in the local/regional team jurisdiction, the more cases the local/regional team would review.
- Teams can choose to review other types of deaths (e.g. cancer, other medical cause deaths).
- Local teams will be responsible for gathering cases records from a variety of sources, including law enforcement, coroner records, hospital records and human service records. Local teams will be able to determine whether they request records ahead of time or whether they ask members of the team to bring records with them to team meetings.
- Local/regional review teams will be required to use the national web-based data collection system to report case findings and identify recommendations for improvements to local policies and practices to prevent child deaths.
- Local/regional review teams will use the comprehensive information collected about each death to identify risk factors and prevention opportunities in a systematic way.
- At minimum, local/regional 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; and
The State Review Team, a volunteer multidisciplinary committee composed of clinical and legal experts in child health and safety, works collaboratively with state staff to review deaths of children less than 18 years of age. 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).
The Child Fatality Prevention Act also created the Colorado State Child Fatality Prevention Review Team (State Review Team). The Team is comprised of forty-five members representing multiple disciplines and agencies, explicitly described in the legislation, and shall be appointed for three-year terms. The 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 voting members selected by majority vote of the Team.
State Review Team duties as required by statute:
- The State Review Team will provide protocols and guidelines for local or regional teams.
- The State Review Team will provide training and technical assistance to all local/regional review teams regarding the facilitation of a child fatality review 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 or regional teams to identify state-level trends and patterns of child deaths and make state-level policy and systems prevention recommendations.
- The State Review Team will provide annual data reports to each local/regional review team that summarizes its local/regional data entered into the system.
- 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 includes 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.
- 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.
- The National MCH Center for Child Death Review: The National Center for Child Death Review is a resource center for state and local child fatality prevention programs, funded by the Maternal and Child Health Bureau. It promotes, supports and enhances child death review methodology and activities at the state, community and national levels.
- A Program Manual for Child Death Review: This manual describes strategies for developing and managing a state or local Child Fatality Review and Prevention program. Suggestions are offered for conducting effective reviews and making recommendations that translate the understanding of how a child died into action to prevent other deaths. This manual was written to provide communities with the information and tools needed to establish, manage and evaluate effective review teams and team meetings. It is meant to serve as a foundation so that communities can adapt the information presented here to fit each local context.
- Injury Control Research Center for Suicide Prevention
- Summary of NHTSA MAP21
New Graduated Drivers Licensing Recommendations
for teen motor vehicle safety
- Understanding Evidence: This site helps you use evidence-based decision-making as you think about strategies to prevent violence in your community.
Colleen Kapsimalis, MPH, CPH
Child Fatality Prevention System Program Manager
REVIEW TEAMS COLLABORATION SITE:
Colorado Child Fatality Prevention System