Conducting Effective Review Meetings

*Beginning the Meeting *

*Sharing Information *

*Clarification *

*Discussion *

*Holdover Reviews *

*Referrals *

*Agency Conflict Resolution *

* Media Relations *

Beginning the Meeting

New members and ad hoc members sign the confidentiality agreement prior to the start of review meetings. Each member agrees to keep meeting discussions and information confidential. Confidentiality is essential for each agency to fully participate in the meetings. A confidentiality agreement signed by team members and required for other meeting attendees should be kept at each meeting by the team coordinator. 

Team members are reminded by the coordinator that: 

The coordinator addresses any logistical issues prior to conducting reviews.

Sharing Information

Reviews are conducted by discussing each child death individually. It can be helpful to use the CDR Report Form as a discussion guide. This will help meetings run smoothly and make report completion easier. Reviews begin with individual agency presentations. Participants provide information from their agency’s records and, when appropriate, distribute it to other members. If information is distributed, it must be collected again before the end of the meeting. 

Information can be shared in the following order: 

  1. The medical examiner presents information on the investigation, autopsy and pending or final determination of cause and manner of death. 
  2. The EMS provider presents the run report and any other data.
  3. The hospital representative or physician shares information from the emergency room and/or other health care setting. 
  4. The law enforcement officer presents information on the scene and other investigations. 
  5. DHS reports on any information it has on the family, child or circumstances. 
  6. Public Health reports on any information it has on the family, child or circumstances. 
  7. Other team members report on any information they have and can share with the team. 
  8. The prosecutor reports on the status of the investigation and any legal action.

Team members may be unable to share information due to confidentiality restrictions or lack of information. If information is needed by an investigative agency, it should be accessed after the team meeting, utilizing standard investigative practices and approaches.


Review team members next ask for clarification or raise questions about the information shared. Prior to moving on with a review, all team members should feel confident that they understand all information as presented or ask for further clarification. 


The team coordinator should ask the following questions, each of which should be answered thoroughly before proceeding to the next one. When all the questions have been answered to the team’s satisfaction, the review should move to the next case.

  1. Is the investigation complete, or should we recommend further investigation? If so, what more do we need to know? 
  2. Are there services we should provide to family members and other persons in the community as a result of this death? 
  3. Are other children at risk of imminent harm? If so, what action should be taken to protect them?
  4. Should we recommend any changes to agency practices or policies based on what we know about the circumstances, cause and manner of this child death? 
  5. What risk factors were involved in this child death? 
  6. Could this death have been prevented?
  7. What do we recommend should be done to prevent another death in the future? 
  8. Who should take the lead in implementing our recommendations for prevention?
  9. Is our review of this case complete or do we need to discuss it at our next meeting? 

Holdover Reviews

Cases may need to be discussed at more than one meeting. Investigation results may be incomplete at the first review. Team members may wish to obtain additional informa­tion from their agencies. A team member or auxiliary member with significant information may be absent. Or a case may continue to progress and need to be updated. 


If a review team identifies the need for services, referrals should be made. Referrals are usually handled by the team member professionally associated with the program or agency that provides the appropriate service. However, any team member can assist in making a referral. Teams should discuss how referrals will be made and who will be responsible for handling them. 

Agency Conflict Resolution

Participating agencies may have individuals with concerns or disagreements regarding specific cases. Reviews are not opportunities for others to criticize or second-guess agency decisions in child death cases. Issues with procedures or policies of particular agencies are sometimes identified; however, agency team members are responsible for any further action taken by their agencies on such issues. 

Teams are not peer reviews. They are designed to examine system issues, not the performance of individuals. The team review is a professional process aimed at improving system response to child deaths. 

Many agencies involved in child death review teams do not have an internal mortality review process. Child Protective Services conducts multi­agency reviews for child fatalities, in which the child or family had prior contact with the agency. Some hospitals conduct internal reviews for in hospital child deaths. For most agencies, however, review teams provide the only forum for reviewing their actions, policies and procedures related to child deaths. 

When conflict among team members interrupts a review, the team coordinator should intervene so the review can progress. The team coordinator can contact the team members outside the meeting to discuss and help resolve conflicts. Sometimes disagreement is both productive and appropriate, but disruption of the review is not acceptable; reviews are to be conducted in a professional manner. 

Media Relations

It is important that teams establish effective working relationships with the media. Media involvement is fundamental to a review team's ability to promote awareness and educate the public regarding child deaths. 

Each team should designate one team member to be the team’s media contact. This person should contact various local media and provide information about the team, its purpose and operation. The media contact can provide the media with statistics and/or reports relating to team activities. Confidential case information is not to be disclosed to the media. Because the objectives and review process are frequently misunderstood by the media, the team coordinator and members need to reinforce that the team is " not a fault­finding panel." 

By viewing the media as a useful tool for promoting child death prevention strategies, team members can more comfortably interact with media representatives. This allows teams to function more effectively and better serve the community.