|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:
1. Sharing, Questioning and Clarifying Case Information
Share, question and clarify all relevant information on the circumstances of
Discuss the investigation.
Identify risk factors.
Recommend systems improvements.
Identify and take action to initiate prevention opportunities.
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:
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.
Health Care Providers
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
2. Discuss the Investigation
Questions that need to be asked regarding the investigation of the death
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.
Who is the lead investigative agency?
Was there a scene investigation?
Was there a scene recreation with photos (especially important for infant
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?
3. Discuss the Delivery of Services
Questions that need to be asked regarding the delivery of services include:
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
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?
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
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:
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.
Systemic (Agency Policies)
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:
The team should always follow up on their recommendations!