Copyright Michigan Public Health Institute September 2005
History of Child Death Review
Models of Review
Roles of Team Members
Conducting an Effective Review
Other Types of Reviews
The Child Death Review Program Manual
The Operating Principles of Child
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The Purpose of Child Death Review
To conduct a comprehensive, multidisciplinary review of child deaths,
to better understand how and why children die, and use the findings to
take action that can prevent other deaths and improve the health and safety
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The Objectives of Child Death Review
The objectives of the CDR process are multifaceted and will meet the
needs of many different agencies, ranging from the investigation of deaths
to their prevention.
1. Ensure the accurate identification
and uniform, consistent reporting of the cause and manner of every child
2. Improve communication and linkages among
local and state agencies and enhance coordination of efforts.
Reviews ensure team members are informed of all
deaths and thus they are more likely to take actions for investigation,
services and prevention.
More complete information may help to identify
cause and manner.
Reviews can lead to modifications of death certificates.
3. Improve agency responses in the investigation
of child deaths.
Meeting regularly can improve interagency cooperation
The benefits of sharing information and clearly
understanding agency responsibilities can make the CDR process worthwhile
in and of itself.
Reviews facilitate valuable cross discipline
learning and strategizing.
Reviews improve interagency coordination beyond
the review meetings.
Reviews promote early and more efficient notification
of child deaths, facilitating more timely investigations.
Sharing information on the type of investigation
conducted leads to improved investigation standards.
Reviews can identify ways to better conduct and
coordinate investigations and resources.
Many teams report that new policies and procedures
for death investigation have resulted from reviews.
mprove agency response to protect
siblings and other children in the homes of deceased children.
5. Improve criminal investigations and the
prosecution of child homicides.
Reviews can often alert other agencies, such
as social services, that other children may be at risk of harm; and they
identify gaps in policies that may have prevented the earlier notification
to these agencies.
6. Improve delivery of services to children,
families, providers and community members.
Reviews can provide new case information to aid
in better identifying intentional acts of violence against children.
Reviews may bring a multidisciplinary approach
to assist in building a case for adjudication.
Reviews can provide a forum for professional
education on current findings and trends related to child homicides.
7. Identify specific barriers and system issues
involved in the deaths of children.
Reviews can identify the need for delivery of
services to families and others in a community following a child death.
Reviews can facilitate interagency referral protocols
to ensure service delivery.
Team members can help agencies identify improvements
to policies and practices that may better protect children from harm.
8. Identify significant risk factors
and trends in child deaths.
9. Identify and advocate for needed changes
in legislation, policy and practices and expanded efforts in child health
and safety to prevent child deaths.
Reviews bring a broad ecological perspective
to the deaths, thus medical, social, behavioral and environmental risks
are identified and more easily addressed.
10. Increase public awareness and advocacy
for the issues that affect the health and safety of children.
Every review should conclude with a discussion
of how to prevent a similar death in the future.
Reviews are intended to be a catalyst for community
Teams are not expected to always take the lead,
but should identify where and to whom to direct recommendations, then follow-up
to ensure they are being implemented. Solutions
can be short-term or long term.
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When review findings on the risks involved in
the deaths of children are presented to the public, opportunities can be
identified for education and advocacy.