The Process Background
The Need for Child Death Review Teams
Michigan’s first review teams were established in June 1995 through a one-year pilot project overseen and funded by the Governor’s Task Force on Children’s Justice (GTFCJ) through a Children’s Justice Act Grant Project a federal grant project administered by the Michigan Department of Human Services (currently Michigan Department of Human Services.) In 1994, the GTFCJ formed a statewide committee of experts in child protection, health and safety to examine the child fatality response system in Michigan and make program and policy recommendations. Concurrently, the Michigan Department of Community Health convened a statewide Sudden Infant Death Syndrome (SIDS) Task Force in part to examine our death investigation and reporting system as it relates to SIDS. Lieutenant Governor Binsfeld’s Children’s Commission was also convened to identify ways to improve the investigation and reporting of child abuse and neglect.
All three initiatives found that we do have statistics on how many children die in Michigan and from what causes, but we know very little at state or local levels about the circumstances leading to child deaths. Often, we do not know what risk factors led to a child’s death or what could have been done to prevent the death. In some cases, we are not sure if a death was an accident or a homicide, particularly in cases of child abuse or neglect. Although the number of children who die from SIDS has decreased, we are not sure how accurately SIDS is reported. In some cases, we simply are not sure why a child has died.
Statistics do not reveal how a community has responded to a child death. How was the child’s death investigated? What services were provided to the family and to community members? Did state and local agencies review their policies, programs and actions as they related to the death or take any action to prevent other similar deaths? Michigan’s system for identifying and responding to child deaths was discovered to have been limited in the following respects:
- Michigan did not have a standardized procedure for in-depth review of child deaths, although the annual State Infant Mortality Report provides a statistical profile of deaths to children under the age of one.
- Reports generated by the state on child deaths are based almost solely on information from death certificates; thus, any information on risks leading to these deaths is limited.
- Michigan did not have a comprehensive system for collecting information on state and local agency involvement with children and their families prior to or after child deaths.
- Except in highly sensational cases, many child deaths go unnoticed except by those who are directly involved with a child.
- Michigan has no system for ensuring comprehensive investigations, accurate identifications, surveillance and reporting of homicides due to abuse and neglect.
- Michigan had no standard child death investigative protocols for death scene investigations, autopsies and reporting. Community resources vary greatly across the state.
- A great deal of misinformation, confusion and disagreement regarding sudden infant death syndrome (SIDS) exists among death investigators, service providers, and families.
- Responsibility of local agencies for the investigation, delivery of services, and implementation of preventive actions is often unclear.
- Poor communication and coordination exists within and among state and local agencies that have a responsibility to the health and welfare of children.
Public Act 167 of 1997 amends Section 7 of the Child Protection Law, to support the establishment and operation of local review teams. It defines local teams as having a team membership of at least the county medical examiner, a representative from local law enforcement, an DHS and local public health representative, and the prosecuting attorney or his/her designee. PA 167 also establishes a State Child Death Review Advisory Team to provide guidance to local child death review teams and to make recommendations to the Governor and Michigan legislature based on local findings.
Public Act 220 of 1995 also amends Section 7 of the Child Protection Law, allowing DHS team members to share information in the Child Protective Services Central Registry.