State Spotlight - Oregon

Last updated:  February 2008

Lisa Millet
Injury Prevention & Epidemiology Section Manager
Oregon Health Division
800 NE Oregon Street, Suite 772
Portland, OR 97232
Phone: 971-673-10597
Fax: 971-673-0990
Email: lisa.m.millet@state.or.us

Website: http://www.oregon.gov/DHS/ph/ipe/cfr.shtml

Tools
Reports
Mortality Statistics Program Description

Administration
The Oregon State Child Fatality Review Team was established in 1989. In 1991, county level child fatality review processes were established. In order to provide technical assistance to these local teams, the legislature established the State Technical Assistance Team (STAT) in 1995 which is housed out of the health department. The annual budget for the state level program is $25,000.00.  Funding for counties goes to District Attorney Offices who operate multidisciplinary teams (MDT) for the investigation of child abuse. The statute that established the MDT requires these teams to set up a CFR process. Funding for the MDT activities also covers the CFR work but it is not funding directed to CFR activities. The amount of funding to the local communities varies.  CFR activities are an add on to the MDT statute. At the state level, there is .25 funded  FTEs and one in-kind full time employee. There are team members who conduct CFR activities as part of their job responsibilities.

Teams
Oregon has both state and local CFR teams.  

State Team Chairperson(s): Karen Gunson, MD, State Medical Examiner and Mel Kohn, MD, State Epidemiologist
The Oregon State Child Fatality Review Team has 20 members that meet twice a year. The purpose of their meetings is to make recommendations and take actions involving statewide child fatality issues. 

Local Teams:
District attorney offices chair local teams in Oregon. There are 35 teams in Oregon, each consisting of approximately ten members. Teams are made up of representatives from at least five key agencies: law enforcement, the district attorney, child protective services, public health and the medical examiner. In many counties, representatives from Emergency Medical Services, Victims Assistance Programs, Juvenile Justice, Fire Department, Schools and local health care providers participate in the process.  Teams conduct retrospective/periodic reviews.

Reviews
Teams review unexpected deaths including homicides, suicides, accidents, unexpected natural deaths and deaths due to an undetermined manner to children less than age 18.  Occasionally, the state team reviews serious injuries/near fatalities.

Purpose
The purpose of CFR in Oregon is investigation, prevention, quality assurance, data collection and to provide services. This is the focus in statute. There is a shift on the state level to primarily a prevention focus. The local teams also work on prevention.

Data
Data reporting forms all completed for all reviews. This is required by Oregon statute. Local teams submit the forms to STAT for entry in the data system. CFR data is stored on a server behind a firewall and is analyzed by the injury epidemiologist. STAT staff at the Oregon Health Division regularly review death certificates from Vital Records. When a child dies in a county different from the county of residence, STAT will fax an Out of County Death Alert to the designated representative of the county of residences. This procedure should assist in assuring that local teams review all deaths. Additionally, some teams call STAT requesting copies of death certificates. Staff also use vital records to create lists of cases that should be reviewed and forward them on to the local District Attorney’s office to assure that case lists match.

Annual Report
An annual report is produced based on the data provided by the local teams. Currently, STAT is in the process of producing a report every two years instead of annually. The report is distributed to CFR team members, legislators and agencies who are involved with children’s issues.

Prevention Initiatives
CFR findings have influenced policy changes on the state level. There was a change in the child abuse statutes to eliminate the religious beliefs exemptions for homicide cases. Statutes to prohibit children from riding in the back of pickup trucks, requiring helmets when skating, riding scooters and skate boards, booster seat requirements and the prohibition of the resale of older cribs that are dangerous in second hand stores have been passed. Additionally, the state newborn handbook has injury prevention pages that include information on safe sleep environment, safety seats and other injury prevention messages. CFR findings have also implemented prevention initiatives at the local level. Examples include: The state developed a suicide prevention plan that is being implemented by local groups. Oregon coastal communities implemented a prevention program to reduce the number of deaths due to logs rolling over kids playing on driftwood. Sandy Oregon established a lifeguard at a public swimming beach on the Sandy River. Fifteen local Safe Kids chapters are partnering with local teams to distribute helmets and safety seats to low income families with children.

Protocols
Oregon CFR has a meeting, confidentiality and child/infant death investigation protocols in place.

Training
Training on the CFR process is presented at the State CPS and State DA meeting. Currently, training on investigation and documentation of suicide cases is being developed.