Successful CDRs

* Examples of Team Members Roles Relevant to the CDR Process *

* Examples of Issues of Concern in Implementing and Sustaining *

* Factors that Contribute to Successful Implementation of CDR *

Examples of Review Team Members’ Roles Relevant to the CDR Process

Team Member Records to Supply for Review Role on Team Actual Members’ Prevention Actions in MI
Medical Examiner Autopsy reports Educate non-medical team members on disease process, mechanism of death/injury. Wrote editorial in paper, did grand rounds re: dangers of bed-sharing w/infants.
Law Enforcement Officer Scene investigation reports/ photos; witness interviews; state uniform crash reports; criminal background checks Give details of incident, inform non-legal team members about role of law enforcement in scene process. Organized Teen Driver Task Force re: loopholes in GDL law, gravel roads & parent involvement in program.
Public Health Representative Home visits, immunizations, WIC, maternal/infant support services, prenatal care, birth records, smoking cessation Share knowledge of child’s/ family’s health histories, services utilized, educate team re: birth info (gest, wt, etc) Wrote grant applications, recruited staff and team members to establish new FIMR program in county.
Social Services Representative Child Protective Services histories on caregivers, participation in parent ed, other support services (homemaking, job skills, etc.) Share knowledge of family social history (divorce, DV, subs. abuse), inform team members about agency’s definition of abuse / neglect. Spearheaded initiative to supply low-income families with new cribs for infants; supplied all police officers with 24-hr grief resources.
Prosecuting Attorney Court proceedings related to case, prior adjudications involving family members/caregivers. Educate team members on what are and are not prosecutable offenses and why; give advice to law enforcement re: scene investigation/documentations. Launched water safety campaign - increased lake patrols and posted signs at each lake, obtained funding for swimming lessons and educational materials. 
Pediatrician Any health records on child Educate team members re: disease processes in children, share any history w/child. Composed letter to high school seniors and their parents to be distributed in area schools, encouraging safe driving behavior during prom and graduation time.
Emergency Medical Services EMS run reports from fatal incident, any prior incidents at that address Share facts about incident, details of scene, impressions of situation in general. Asked social workers to help get smoke detectors in homes that lacked them.
Hospitals ER records, surgeries, in-patient care, OB/GYN info Share health records, inform team about hosp protocols. Added safe sleep info to “Welcome Baby” gift bags.
Community Mental Health Marklar Educate team about psych meds, individual and group services available.

Partnered w/local council to develop community crisis response to death of a child.


Probate or Family Court

Delinquency histories, probation records

Inform team about court proceedings, options available for youth in trouble. Suggested change to youth probation protocol when suicide risk is present.
School Representative Marklar Educate team on school policy  & practices, curricula. Tailored ISD annual staff workshops to address certain CDR findings.
Human Service Collaborative Rep History of board’s activities related to cause of death/injury Advise team on what is being or could be done on an issue. Started a new SAFE KIDS chapter in the county.

Examples of Issues of Concern in Implementing and Sustaining

Category of Concern Specific Example Possible Solution


Team chair was appointed by supervisor, does not truly buy into CDR process.

Send team chair to state or national CDR training; provide TA & support.


Urban team overwhelmed by caseload; rural team experiences attrition from lack of cases, need for review meetings.

Urban team focuses on one cause of death per meeting; rural team begins reviewing serious injury, prevention.


Team has consistent problem with key members missing meetings.

Have members designate alternates; coord gets key reports before meeting.


Team coordinator feels overwhelmed by administrative tasks of running team.

Other members take turns completing various administrative tasks of team.


Agency members without history of working together do not trust each other.

Choose simple initiative that impacts both to collaborate on, building trust.


New team struggles in deciding parameters of team’s activities.

Team uses written team protocols as guide, adapting to community’s needs.


Team feels disconnected from state level team due to lack of inter-communication.

Local coords. compile findings, send to state team, ask for periodic feedback.


Team conducts thorough reviews, but fails to complete/submit case reports.

Appoint agency data analyst to team; sole task is case report completion.


Meetings begin to lack overall focus, effectiveness, efficiency of time.

Reiterate goals of process before each meeting; send members to training.


Team unsure of how quality of their reviews compares to other teams in the state.

Through coord. meetings, make contact with other teams, attend their reviews.


Team seems unable to get past tragic events to see bigger picture of prevention.

Obtain/share examples of other teams’ successes with prevention initiatives.

Factors that Contribute to Successful Implementation of CDR

Factor Specific Example Why This Contributes to Success

State Support

State agencies and government support the concept of the CDR process.

Although a bottom-up process, agreement to participate is often top-down.


Enabling & protecting legislation relating to CDR is passed at the state level.

Gives legal basis for sharing sensitive information; legitimizes process for some.

Funding TA and Support

Funds to cover community consultants are appropriated by participating agency(ies).

Expertise of CDR consultants facilitates formation and sustainability of teams.

Housing of Program

CDR staff are housed in a neutral location, with committed housing organization.

Non-threatening to other disciplines involved; lessens turf issues.

Pre-Organizational Seminar(s)

A state with few or no local teams holds  regional seminars for human service reps.

Introduces the idea of the CDR process to multidisciplinary audience at one time.

Organizational Meeting

Team convenes first meeting as organizational only; no reviews are done.

Provides opportunity to get acquainted, set parameters before attempting reviews.

Interagency Agreement

Agency directors sign joint agreement to participate in the CDR process.

Solidifies multi-agency commitment and idea of shared ownership in the process.

Confidentiality Statements

All members sign annual confidentiality statements before sharing information.

Further assures members/agencies still wary of liability associated with CDR.


Statewide training provided to new local and state level team members annually.

Informs members about types of death; builds skills for conducting reviews.

Retro/Practice Reviews

Team chooses a number of deaths from recent past as first batch of reviews.

Serves as review practice; raises comfort level of members with the process.

Buy-In of Core Members

Agency reps required by law to be present are committed to CDR; attend all meetings.

Sets tone for other members to follow; raises perceived importance of process.

Ad Hoc Membership

Team coordinator invites individuals who were involved in cases to those meetings.

Gives members clearer pictures of events; facilitates prevention discussions.

Access to Records


Adequate records on each death are made available to the team for review.

Increases team’s ability to understand the circumstances of and report on the death.

User-Friendly Reporting System

Reporting system is easy to use, includes all important info, provides data feedback.

Encourages teams to submit reports, allows them to generate summary data.

Positive Focus

Review focus remains on prospective actions as opposed to finger-pointing.

Reassures members that is a public health process and not a witch hunt.

Deaths Reviewed

Broad base of deaths reviewed is inclusive of all preventable deaths, birth to age 18.

Improves team’s ability to identify trends, enhances prevention/policy development.

Dissemination of Findings

Findings/recommendations are reported to professionals, legislators, the public, etc.

Maximizes impact of the review process; reinforces members’ commitment.