Effective Review Meeting
Copyright Michigan Public Health Institute September
are different approaches used by teams around the country to conduct death
reviews. But there are certain basic steps that if followed, will help
lead to complete and thorough reviews that address the maximum number of
issues involved in children’s deaths:
Six Steps to Effective Reviews
question and clarify all case information.
2. Discuss the investigation.
3. Discuss the delivery
4. Identify risk factors.
5. Recommend systems improvements.
and take action to implement prevention recommendations.
Question and Clarify All Case Information
goal of this step is to understand all of the circumstances leading to
or involved with the death incident. Team members should know before the
meeting which cases will be reviewed, so that they are sure to bring all
case relevant information to the meeting.
the review, agency representatives take turns sharing the information they
have on the child, the family and the circumstances of the death. Due to
confidentiality constraints, most teams either do not share written material
or distribute the material only for review during the meeting, collecting
and destroying it at the end of the meeting. Case reviews are only effective
if team members show up for the meetings and bring all pertinent information
is important to try and share information in a logical order. One suggestion
for the order of this information sharing process is:
order to be most effective, team members should feel free to ask questions
of the person presenting the case information, either during their presentation
or after they have finished, depending upon the level of formality of your
team. The person sharing information can then clarify what they know about
the child, family or incident.
after all members present have shared their case information, the team
still feels that there are gaps in their understanding of any aspects of
the death, it may be best to table the discussion until the next meeting.
Then information not able to be shared at that time due to team members’
absences or any other reason may be brought to the following meeting, allowing
for a more complete review of the death. You may wish to assign the obtaining
of that needed information to a specific team member so that there is a
higher likelihood that it will be available at the next meeting.
CDR team may also review a case where information is abundant, but there
are complex issues involved that the team wishes to explore in greater
depth. Such cases may be brought back to review agendas multiple times,
over a period of months, until the team is comfortable that all areas of
concern have been properly addressed.
Discuss the Investigation
that need to be asked regarding the investigation of the death include:
is the lead investigative agency?
there a death scene investigation?
there a death scene recreation with photos (especially important for infant
other investigations conducted?
were the key findings of the investigation(s)?
the team feel the investigation was adequate?
the investigation complete?
more do we need to know?
the team have suggestions to improve the investigative system?
clarification process is not meant to determine if a person or agency handling
the investigation of a death made mistakes in some way. It is to determine
if all pertinent questions that the team needs to know about the circumstances
of the death have been answered. Does the reading of the investigative
reports give the team a clear picture of what led to this child’s death?
If not, it may be appropriate for the team to recommend to the lead agency
that further investigation is warranted or they may suggest that agency
policy and protocol be examined to be sure that future child death investigations
are as complete as possible.
Discuss the Delivery of Services
that need to be asked regarding the delivery of services include:
there any services that the family was accessing prior to the death?
services provided to family members as a result of the death?
services provided to other children
services provided to responders, witnesses or community members?
there additional services that should be provided to anyone?
will take the lead in following up on these service provisions?
the team have suggestions to improve service delivery systems?
with the clarification of the investigative process, these questions are
not meant to place blame, but to ensure that those who may be touched by
a death receive needed support services.
can look at who that might be as a series of concentric circles. Siblings
or any other family member being at the center, then friends and schoolmates
of the deceased, responders to the death or administrators involved in
the life or death of that child, finally to the larger community. Obviously,
the smaller the circle, the more intensive the services may need to be.
A community member who did not know the child may benefit from information
about the type of death and ways it can be prevented, such as a media campaign.
A parent or sibling may need one-on-one counseling for an extended period
of time in order to cope with the death.
Identify Risk Factors
the risk factors involved in a child’s death during the review can lead
to recommendations that the team believes could reduce those same risk
factors for other children, thereby preventing future deaths. That is why
this step is so important. It can sometimes be difficult to see the big
picture where risk factors are concerned. The team may have to think outside
the usual boundaries in order to touch on all risk factors that may have
contributed in some way to the death. Grouping risk factors into general
categories can help guide this discussion:
is not an exhaustive listing and these are meant only as broad groupings.
The team can discuss why they believe the risk factors involved may or
may not fit into one or more of these categories. Indeed, that is one of
the main functions of identifying them in this way. Although it is always
easiest to just mark “behavioral” and move on (“if person x hadn’t done
y, then z would still be alive,” etc.), teams should challenge themselves
to look deeper into what may have influenced the behavior in question and
any other angles on the situation that may not be immediately obvious.
Teams should try to examine the death from as broad an ecological perspective
is important to identify the risk factors involved in each death, as these
become the basis upon which a team will formulate its findings. These findings
are in turn used to generate recommendations for improved investigations,
service delivery, changes in systems, local ordinance or state legislation
or community or state prevention initiatives. These systems improvements
and prevention programming are the ultimate goal of a CDR process that
is based on the public health model, to keep children safe, healthy and
Recommend Systems Improvements
all the facts of the case have been shared and discussed, there may be
issues involving agency response that need to be addressed. Generally,
the team member representing the agency in question will explain their
protocols to the team. In this way, team members learn more about what
the parameters of others’ responsibilities are, including the legal purviews
of the organizations that each member represents.
as mentioned previously in the steps regarding clarification of the investigation
and service delivery, the team may identify gaps in policy and procedure
in response to the death. The result of this discussion may be that an
agency representative brings the review findings back to their supervisors.
If the findings relate to a very large and bureaucratic agency or one that
does not have official representation on the team, the team may have to
make efforts to contact the agency in question regarding their recommendations.
Phone calls or an invitation for an agency representative to attend the
next meeting may be the best way to approach this. If inadequate response
is received from the agency from these initial attempts, a letter regarding
the matter may need to be sent from the review team to the director and/or
appropriate supervisor(s) at the agency.
is important that these recommendations be handled in a diplomatic fashion,
recognizing that each agency is doing their best with what resources are
available. Try to convey that your team wishes to give the agency a “heads
up” on a matter that might cause them difficulty in the future. Suggest
that their purposes could be met more fully if the issue is addressed.
Try to keep your comments limited to the perceived gap or barrier and not
include too much direction on what the team thinks should be done to address
it. Request that the agency provide feedback to the team regarding any
decisions that the agency may make on the matter.
Identify and Take Action to Implement Prevention Recommendations
review should never be considered complete by the team until the important
question is asked: “What are we going to do to prevent another death?”
The review team does not necessarily have to be the group that sees the
prevention action through from start to finish. Instead, they can play
the important role of being the catalyst for change, the spark that starts
a prevention campaign. In other words, the team's effectiveness in prevention
can be simply in knowing where to send its recommendations for maximum
are a number of places to send such recommendations and the team should
be aware of these options in their area:
team should always follow up on their recommendations. Such follow-up fosters
accountability and provides recognition to those implementing the CDR recommendations.