Team Meeting Protocols So how exactly does this review process work? What are the steps that a Child Death Review (CDR) team should follow in completing reviews? The answers to these questions may vary widely by state and even within a state among local teams. We have included examples of flow charts of review team processes from three different states. You may wish to use these as frameworks for putting together a flow chart for your own team’s process, once it has been agreed upon by team members. Such a chart may be useful to make clear to all involved how the actions of the team and its member agencies relate to one another, as well as to communicate to outside entities how your review team functions. Review Meeting Steps There 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: The Six Steps to an Effective review include: Share, question and clarify all relevant information on the circumstances of the death. Discuss the investigation. Discuss services. Identify risk factors. Recommend systems improvements. Identify and take action to initiate prevention opportunities. 1. Sharing, Questioning and Clarifying Case Information The goal of this step is to understand all of the circumstances that led to the death. Team members should know before the meeting which cases will be reviewed, so that they may be sure to bring any case-relevant information to the meeting. Included in the Sample Form section is a sample Meeting Summary Sheet that can be sent out by the team coordinator to all team members several days or even a few weeks before the meeting. At 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 and then collect and destroy them at the end of the meeting. Case reviews are only effective if team members show up for the meetings and bring all pertinent information with them. One suggestion for the order of this information sharing process is: Medical Examiner/Coroner EMS/Fire Law Enforcement Health Care Providers Social Services Public Health Prosecuting Attorney Others In order to be most effective, team members should feel free to ask questions of the person presenting the case information, either during their presentation of it or after they have finished, depending upon the level of formality of your team. The person sharing information can then further clarify what they know about the child, family or incident. If 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 any 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. A 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. 2. Discuss the Investigation Questions that need to be asked regarding the investigation of the death include: Who is the lead investigative agency? Was there a scene investigation? Was there a scene recreation with photos (especially important for infant sleeping deaths)? Were there other investigations conducted? What were the key findings of the investigation(s)? Does the team feel the investigation was adequate? Is the investigation completed? What more do we need to know? Does the team have suggestions to improve the investigative system? This clarification process is not meant to determine if a person or agency handling the investigation of a death “blew it” in some way. It is merely 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 may be 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. 3. Discuss the Delivery of Services Questions that need to be asked regarding the delivery of services include: Were there any services that the family was accessing prior to the death? Were services provided to family members as a result of the death? Were services provided to other children (schoolmates, etc.)? Were services provided to responders, witnesses or community members? Are there additional services that should be provided to anyone? Who will take the lead in following up on these service provisions? Does the team have suggestions to improve our service delivery systems? As with the clarification of the investigative process, these questions are not meant to place blame. As a community, we have a responsibility to make sure that those who may be touched by a death receive any support services that they may need. We 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. 4. Identify Risk Factors Identifying 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 in 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: Medical Social Economic Behavioral Environmental Systemic (Agency Policies) Product Safety This 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, than 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 as possible. It 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 agency policy and practice, local ordinance or state legislation, or community/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 safer, healthier and protected. 5. Recommend Systems Improvements Once 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. Then, 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 findings of the team 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, perhaps 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. It 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. 6. Identify and Take Action to Implement Prevention Opportunities A review should never be considered completed by the team until the ever-important question is asked: What are we going to do to prevent another death? Most deaths due to unintentional injury have a variety of preventive avenues that can be explored by the team. Reviews of homicides and suicides, although often more complex, should be seen as opportunities to examine the issues involved, in order to identify any preventive action that could possibly be taken by individuals, agencies, the larger community or the state. If your team reviews deaths due to natural causes, the question as to how other deaths can be prevented may sometimes go unanswered. But many deaths due to natural causes have aspects of preventability that can and should be addressed by the teams that review them (availability and adequacy of prenatal care, compliance with medical treatment regimens, etc.). The review team does not necessarily have to be the ones to see 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 impact. There are a number of places to send such recommendations and the team should be aware of all these options in their area: Key Individuals Agencies New Coalitions Existing Groups The team should always follow up on their recommendations!