Child Fatality Review

Working together in Georgia to Save children’s Lives

Teri Covington, MPH, DirectorNational Center for Fatality Review and Prevention

CFR is:An engaged, multidisciplinary community, telling a child’s story, one child at a time, to understand the causal pathway that leads to a child’s death to identify pre-existing vulnerabilities and circumstances- in order to identify how to interrupt the pathway for other children

…. generating a broad spectrum of data for an ecological understanding of the individual, community, and societal factors that interact at different levels to influence child health and safety

….Then taking action to improve systems and prevent deaths.

Child Fatality Review in 2016

CDR in 50 states

1250 local and state

GuamDepartment of Defense

Tribes

Georgia CFR: Modeled after Best Practice

• Local review committees in every county• Strong support and

training to local committees• High number of reviews

that meet Healthy People 2020 objectives• Use of the National Case

Reporting System• Strong state support• State Review Board• State attention to

findings

SUID and Sudden Death in the Young Case Registry

A simple process of sharing information

to understand the WHY

but a complex process of group wisdom and shared responsibility for getting it

right to prevent other deaths

Why child fatality reviews?

CDC, Vital Signs: Child Injury, http://www.cdc.gov/vitalsigns/childinjury/

Essential Elements•Multi-disciplinary.• Telling a story through the sharing of case information from multiple sources.• Focused on improving systems and prevention of deaths; not culpability.• Balance between individual cases and accumulation of fatal and non-fatal data for trends.

Systems Improvements

Prevention

Investigation

Investigation, Identification, diagnosis

Review

Prevention

Improved agency systems

Improved identification, diagnosis and reporting

Improved communication

Review

ThePower to

Prevent Child DeathsFrom Data to Action

Local team recommendat

ion

State Child Fatality

Review Board

Governor & legislature

Acted on statewide

Shared locally Acted on locally

• HRSA MCHB• CPSC• SAMHSA• CDC, • Safe Kids and drowning• Parent Heart Watch• National Commission to Eliminate Child

Fatalities

Local reviews effect national policy…..to name a few

78% of 503 deaths reviewed were preventable

211 recommendations for prevention were made by local teams

What will you do at the state level?

Some of the Actions in Georgia• SB 138 allows agencies to share data (SB 138). CFR can now share data with

Dept of Public Health, Div of Family and Children Services, and other state agencies without formal requests.

•CFR partnered in 2015 with Dept of Public Health (DPH) and Div of Family and Children Services (DFCS) to create a statewide Safe to Sleep Campaign, to begin in 2016.

• GBI, using data provided by CFR, created a video on safe sleep, and hosted a symposium in October 2015 that trained 400 scene investigators on best practices. Another safe sleep video was produced; a 30-second PSA featuring the Governor and First Lady.

• GBI ordered 500 gun locks to distribute to CFR teams and DFCS staff.

Prevention and Systems

Change

Fatality Review

DFCS Reviews

Internal Agency

CFR Reviews

Challenges

• Addressing disparities and inequalities• Funding • Political support to

implement recommendations

Keep Your Eyes on the Prize

2014 CFR Annual Report Data Overview

Malaika Shakir, MSWGBI/CFR Program Manager

All Reviewed Child Deaths, GA, 2014 (N=503)

Exposure

Poison

Undetermined

Asphyxia

Drown

Motor Vehicle Crash

Sleep-Related *

0 20 40 60 80 100 120 140 160 1802267121315

284447

7990

158

All Reviewed Deaths by Gender, GA,2014 (N=503)

324

179MaleFemale

All Reviewed Deaths by Race/Ethnicity, GA, 2014 (N=503)

White

African

-American

Hispan

ic

Multi-R

ace

Other R

ace0

50100150200250300

189265

28 15 6

LEADING THREE CAUSES

INFANT SLEEP-RELATED

MEDICAL

MOTOR VEHICLE-RELATED

Sleep-Related Infant Deaths, GA, 2014 (N=158)

96 Sudden Unexplained Infant Death (SUID) with prominent risk factors (bed sharing, prone, sleep items)

52 Asphyxia (e.g. suffocation, overlay, positional asphyxia)

8 SUID Medical (medical conditions present/medical cause and manner of death; sleep environmental factors could have contributed to the death)

2 Sudden Infant Death Syndrome (SIDS) diagnosis of exclusion when no other risk factors are identified

Sleep-Related Infant Deaths, GA, 2014 (N=158)

61% were African-American, 31% were non-Hispanic Whites, 6% percent were Hispanic and 2% were multi-race

Males accounted for 59% (93) 65 females

66% of the deaths were among infants less than four months old (N=158)

60% of the deaths occurred in an adult bed; 21% occurred in a crib or bassinette (N=158)

When known, 52 infants were found on their back; 61 were on their stomach (N=153)

When known, 65% of the deaths involved bed sharing (N=153)

Medical Deaths, GA, 2014 (N=90) Males accounted for 62% of all medical deaths (56);

there were 34 female deaths African-American children accounted for 61% of all

medical deaths (55) compared to a combined total of 35 White, Hispanic, Multi-race and Other race children

Leading causes include: Cardiovascular (21) Pneumonia (14)Asthma (9) Neurological/Seizure Disorder (6)

Motor Vehicle-Related Deaths, GA, 2014 (N=79)

Males comprised 63% of all reviewed MVC deaths (50)

33 African-American, 41 White, 4 Hispanic, 1 Other race

Children ages 15 to 17 accounted for almost half (43%) of all reviewed MVC deaths

44% of all reviewed MVC deaths were passengers (35)

There were 23 pedestrian deaths; 8 were ages 15-17, 7 were ages 1-4, 8 were ages 5-14

There were 16 driver deaths; 13 were ages 15-17 and 3 were ages 10-14

We owe it to them to do SOMETHING! INDIVIDUALLY & COLLECTIVELY

Talk with our families, friends, neighbors, co-workers, and even STRANGERS about:

Infant Safe Sleep Gun Safety Water Safety Fire Safety Motor Vehicle Safety

THANK YOU!!  

Georgia Bureau of InvestigationChild Fatality Review Division

3121 Panthersville Rd.Decatur, GA 30034

(404) 270-8714 Officewww. gbi.ga.gov/cfr

Snapshot of CY 2014 • The total number of reports to the Division: 102,003• Screen Outs: 24,813– The total number of reports assigned to Child Protective Services (CPS) workers:

77,190• 34,464 (45 percent) were assigned to Family Support • 42,726 (55 percent) were assigned to Investigations

• The total number of children in Foster Care at some point in 2014: 15,085 • The total number of Family Preservation cases: 9499

In order for a child’s death to be included in this report, the family must have had prior Child Welfare history with the Division within 5 years of the death. As this illustration shows, the deaths under consideration are a much smaller subset of the total child deaths that occurred.

N=1,515

N=503

N=296

N=169

All child fatalities in the general Georgia population for 2014

2014 child deaths reviewed by CFR

2014 fatalities reported to the Division (regardless of history) 

Subset of fatalities in this report

Universe of Child Deaths Included in the Report

Manner of Deaths

20%n=33

14 %n=24

32%n=54

2%n=4

6%n=10

26%n=44

FatalitiesAccident (N=33) Homicide (N=24) Natural (N=54)Pending (N=4) Suicide (N=10) Undetermined (N=44)

The child deaths included in this chart are those with a previous Child Welfare history within the past 5 years. Natural and accidental deaths comprise 52% of the total.

Ages of Children who Died

0

20

40

60

80

63

1417

106 7

41 2

46 6

23

8

3 5 4 4

Age at Death

The child deaths included in this graph are those with a previous Child Welfare history within the past 5 years. More than anything else this chart illustrates the vulnerability of the youngest children in Georgia. Most deaths under 2 are related to medical issues or are sleep-related.

Heat Map of Child Deaths

The child deaths included in this map are those with a previous Child Welfare history within the past 5 years. Several experts, including those from Georgia State University, have noticed a similarity with other heat maps depicting child-related concerns.

Child Fatality Rates Per 100,000 Children, by Region, 2014

<44-66-88-99-10>10

Deaths of Children with Prior DFCS History Compared to the General Population

• The five-year look back for determining prior Child Welfare history encompassed 676,827 children.

• Of these 169 died during 2014.• This is slightly less than 25 deaths per 100,000

children• The child fatality rate in 2014 was 61 per 100,000

children in Georgia

Linear Model

Presenting Family

ProblemIntervention

Safe Child

Linear Model

Unsupervised Child

Parenting Classes

Safe Child

Unsafe Child

Complexity ModelSafe Child

Presenting Problem

Intervention

Unsafe Child

Complexity ModelSafe Child

Unsupervised Child

Parenting Classes

Extreme Complexity ModelPresenting

Family Problem

Intervention

Safer Child

Safe Child

Unsafe Child

Presenting Family

Problem

Presenting Family

Problem

InterventionIntervention

Extreme Complexity ModelNo

social support

Link to church

Safer Child

Safe Child

Unsafe Child

Substance Abuse Schizophrenia

Mental Health Treatment

Substance Abuse Treatment

Wicked Problem Model

Unsafe Child

Family Problem

Intervention/Other Agency

Family Problem

Family Problem

Safer Child

Intervention/Other Agency

Intervention/Other Agency

ConfoundingFactor

ConfoundingFactor

Confounding Factor

Safe Child

Confounding Factor

Wicked Problem Model

Unsafe Child

Substance abuse

SA Treatment/Community

Service Board

Schizophrenia No Social Support

Safer Child

Mental Health Tx/Psychiatrist

Link to Church/First Baptist

Only open during work hours No transportation Unstable

Employment

Safe Child

Changing Family Composition

Child Death Summary Statements• Children two years of age or younger, account for 56 percent (94) of the 169 deaths. 53 of

these deaths were sleep related.• Children in South Georgia, roughly from Bibb county southward, with a prior Child Welfare

history with DFCS, have a fatality rate that is at least 50% higher than north of that line. • There were four homicides of children in care during 2014, two of which were caused by

the caregiver. One teen was on runaway status and was stabbed. The fourth was an accidental shooting.

• 58 percent (98) of the deaths were children whose caregivers had an alleged history of substance abuse.

• 38 percent (65) of the children who died had caregivers who had been convicted of crimes

What Will It Take to Improve These Outcomes?• Long-term, multidisciplinary efforts in committed communities that focus on having

access to adequate resources and services. • Integration of trauma-informed practice with all partners who work with children

who have suffered abuse or neglect at any point in their life. • Ongoing community engagement, consultation and involvement.• Strengthen Georgia’s response to child abuse and neglect through the adoption of

the research-informed child welfare practice model Solution-Based Casework as a foundation to Georgia’s Practice Model.

• All elements of the Blueprint for Change.