The Purpose of CDR

* Operating Principle *

* Goal *

* Objectives *

* Achieving Objectives *

Operating Principle

The death of a child is a community problem. The circumstances involved in most child deaths are too multidimensional for responsibility to rest in any one place.

Goal

The Goal of Child Death Review Teams is to improve our understanding of how and why children die, to demonstrate the need for  and to influence policies and programs to improve child health, safety and protection and to prevent other child deaths.

Objectives

  1. Accurate identification and uniform reporting of the cause and manner of every child death.
  2. Improved communication and linkages among agencies and enhanced coordination of efforts.
  3. Improved agency responses to child deaths in the investigation and delivery of services.
  4. Design and implementation of cooperative, standardized protocols for the investigation of certain categories of child death.
  5. Identification of needed changes in legislation, policy and practices, and expanded efforts in child health and safety to prevent child deaths.

Achieving Objectives

  1. Accurate identification and uniform reporting of the cause and manner of every child death.

    Child death review teams provide a forum to ensure that relevant information is shared and available to determine why a child has died and to better understand all the contributing factors leading to a death. A team's multi‑disciplinary membership enables all team members to better understand how and why a child has died and facilitates more accurate reporting. When child death review teams identify a lack of sufficient information to accurately determine how a child has died, the systematic collection of more information is agreed upon. In addition, use of the child death review report can improve understanding of cause and manner of death.  St. Clair County reported that, “We are going back to review old cases because we realized how little we really know about these deaths.”  

    Using the state's Child Death Review Program as a resource, the teams can identify and review deaths of children who resided in their counties but died elsewhere. Sometimes these deaths go unnoticed to team members. Reviews also ensure that team members are informed of all deaths or learn about deaths sooner than usual and are thus able to take action in a more timely manner.

  2. Improved communication and linkages among agencies and enhanced coordination of efforts. 

    Meeting regularly to talk about child deaths can significantly improve interagency cooperation and coordination. The benefits of sharing information and clearly understanding agency responsibilities can make the process worthwhile even if new information doesn’t surface at a review. Kalamazoo County reported that,  "Confidentiality was a huge problem for us at first. Now, we all know why we are here and the issue went away. It took a couple of meetings to mesh law enforcement and the medical people, but, in doing the reviews, our barriers fell down." Berrien County found that,  "We have a better understanding of our individual roles in each kid’s death."  And Kent County reported that, "Even when we don’t take specific action because of the review, we are all obtaining valuable cross-discipline training and learning to work better together." 

  3. Improved agency responses to child deaths in the investigation and delivery of services. 

    Child death review teams promote quicker, more efficient notification of child deaths, thus enabling mandated investigators to conduct more timely investigations. Team reviews can help identify problems regarding the coordination of investigations or the investigative responsibilities of different agencies. Reviews can identify ways a community can better conduct and coordinate investigations and can help to improve investigative resources.  

    The team may decide to conduct their reviews within a short period of time after the death, so that the review becomes a part of the investigative process.  Other teams may choose to conduct more retrospective reviews, and use the review not as an investigative tool for a specific death, but as a way to improve future investigations. 

    Many of the counties that conduct child death reviews have developed new policies and procedures for death investigation. Some of these innovations include:

    • A policy whereby police always visit the scene of an unnatural death to a child under the age of one.
    • A policy to notify Michigan Department Of Human Services in the event of all accidental deaths to children.
    • Efforts to provide special training to EMS providers for working effectively, yet with empathy, for the victims and families at the scene.

    Child death reviews can enhance criminal investigations and improve the response of the criminal justice system to child homicides. A number of teams have identified child abuse deaths that initially appeared to be accidental or natural. In addition, a number of counties report that they are much better informed on the very real occurrence of sudden infant death syndrome (SIDS) as it is distinguished from accidental or intentional suffocation.

    Reviews can improve the delivery of services to families and others in a community following a child death. Bereavement services for families, stress debriefing services for first responders, counseling services in schools following traumatic deaths, and the protection of siblings in child abuse homicides are some of the services that have improved as a result of child death reviews in the pilot counties.

  4. Design and implementation of cooperative, standardized protocols for the investigation of certain categories of child death.

    Child death investigations vary greatly across the state, depending on resources available to counties and levels of coordination among agencies. Reviews can assist agencies in developing standardized protocols to investigate and deliver services. The State of Michigan Protocols to Determine the Cause and Manner of Sudden and Unexplained Child Deaths have been developed and endorsed by major state agencies. Child death review teams can help to ensure utilization of these protocols. Standardized protocols within and among counties can clearly define roles and standardized procedures, resulting in more accurate reporting of child deaths statewide. Several counties have already improved local protocols in a number of areas:  

    • Working with first responders to better protect child death scenes.
    • Implementing a multi-agency response team to investigate child death scenes.
    • Developing hospital emergency room protocols to better identify child abuse.
  5. Identification of needed changes in legislation, policy and practices, and expanded efforts in child health and safety to prevent child deaths.

    The Child Death Review Program’s ultimate purpose is to prevent additional child deaths. Every review of every child death concludes with a discussion of how the team can prevent another similar death in the community. Teams can focus their discussion on short and long-term interventions relating to policy, programs, and practice. Teams are not expected to design and implement recommendations; reviews are intended to catalyze community action. Teams should identify the best way to translate prevention recommendations into action. Individual agencies or team members can assume responsibility and work with existing prevention coalitions or establish new ones. The reviews have led to many initiatives, some involving short-term, easy to fix problems others requiring long-term, extensive planning efforts.

    The State Child Death Advisory Team will develop state level recommendations for policy and practice in child health, safety and protection based on the collective experiences and recommendations of the county review teams.