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Child Death Review and Injury Prevention


The death of a child is a tragedy for both the child's family and the community. It is doubly tragic that most children die from injuries and that most of these deaths could have been prevented. In response, states and counties have established a system to examine the circumstances of each child death. This system is called Child Death Review. These reviews are conducted by multi-disciplinary teams or boards that routinely and systematically examine the circumstances surrounding child deaths in a given geographical area and a given age group. Most of these review teams not only work to determine the causes of childhood deaths but also make recommendations for changes that may reduce the risk of children dying.

Regular multi-agency review of unexplained childhood deaths began in Los Angeles County, California in 1978. By mid-1997 there were multi-disciplinary state or local teams in all 50 states and the District of Columbia (1). Typically, these teams are, at minimum, composed of a coroner and representatives from medicine, law enforcement, public health, social services, education, child protective services, and mental health.

Policy & Details

Every state and county shall have a multidisciplinary team that reviews the causes and circumstances of each child's death to find hazards that may place other children at risk from neglect, abuse, violence, and unintentional injuries. This information should be used to prioritize and focus community prevention activities and not exclusively to establish blame.

Early on, most child death review teams were established to identify and to prevent child deaths caused by abuse and neglect and to gather the necessary information to take action against the guilty. Now, in many areas, the charge to these review teams has been expanded to include an in-depth investigation of all child deaths to gain knowledge that may be used for prevention. This prevention-oriented approach not only addresses maltreatment-related deaths but also promotes better understanding and greater awareness of all the causes of child deaths at both state and local levels.

In most cases, a system that includes local teams that report to a state body is best. A single state-level team cannot bring the level of vitality to the area of prevention that a local review process can. Local multi-disciplinary, multi-agency teams review local deaths, make recommendations for local changes, work toward the implementation of those recommendations, and provide information and recommendations to the state team. State teams review information and recommendations from the local groups and make state-level recommendations for new laws, focused enforcement, agency policy changes, etc. If the population is sufficiently large, the local team should be at the county level. However, several counties may join together if the population or number of childhood deaths is relatively small.


A multidisciplinary child death review team has the ability to gather, examine, and synthesize detailed information about the cause and circumstances of childhood death. This information is particularly useful because it provides in-depth information that is not available from reports that aggregate population statistics. Death review information is especially useful in small counties where small numbers complicate the interpretation of population statistics. The teams may make recommendations themselves or, through agreements that control confidential information, they may transfer their insight to injury prevention specialists.

In Philadelphia, Pennsylvania child death review information has led to increased enforcement of child safety seat laws, pedestrian safety initiatives, and community focus on the need for smoke alarms (2).

The 1997 British Columbia (Canada) Child Death Review Team Report used data to make recommendations concerning the use of child safety seats and the risks of driving while under the influence of alcohol or other drugs (3).

The Arizona Child Fatality Review Team recently released its 1999 report and concluded that nearly a third of all child deaths there could have been prevented. Based upon their findings, the team presented recommendations to both policymakers and the general public. Examples of these data-driven recommendations include: supporting stepped-up enforcement of seat belt and child safety seat laws; advocating for laws to protect children from injuries related to falling from the cargo bed of pickup trucks; and supporting legislation that would require all handguns sold in Arizona to have a locking device. The team also recommended that equipment and training on the installation and use of child safety seats be provided to those who transport young children (4).

By monitoring the occurrence of childhood deaths and performing an appropriate investigation when deaths occur, child death review teams have a unique ability to gather the detailed information that is necessary for effective injury prevention activities. Continually functioning multi agency review teams with consistent membership have the potential to accelerate progress in understanding the circumstances of violence and unintentional injuries that lead to child death and to mechanisms of prevention. Collaboration among agencies enhances the ability to determine accurately the cause and circumstances of death. Information about the death of one child may lead to preventive strategies to protect the life of another. (5, 6, 7)


Teri Covington, Program Director
Michigan Public Health Institute
Child Death Review Program
2438 Woodlake Circle, Suite 240
Okemos, MI 48864
Phone: (517) 324-7330
Fax: (517) 324-7365

Stephen J. Wirtz, PhD
Research Scientist II
611 North 7th Street MS39A
P.O. Box 942732
Sacramento, CA 94234-7320
Phone: 916-445-8803
Fax: 916-323-3682

Robert Schackner, Director
Arizona Child Fatality Review Team
1740 West Adams, Room 202
Phoenix, Arizona 85007
Phone: (602) 542-1875
Fax: (602) 542-1843

For Further Information


1. Bonnie RJ, Fulco CE, Liverman CT (Eds). Reducing the Burden of Injury: Advancing Prevention and Treatment, Chapter 3, Surveillance and Data. Washington, DC: National Academy Press, 1999.

2. Onwauachi-Saunders C, Forjuoh SN, West P, Brooks C. Child death reviews: a gold mine for injury prevention and control. Injury Prevention 5(4): 276-279, 1999.

3. Office of the Children's Commissioner, British Columbia. Review of Child Fatalities, January 31, 1997. Available online:, June 1, 2000.

4. Arizona Child Fatality Review Team. Sixth Annual Report. Phoenix, Arizona: Arizona Department of Health Services. November, 1999.

5. American Academy of Pediatrics, Committee on Child Abuse and Neglect and Committee on Community Health Services. Investigation and Review of Unexpected Infant and Child Deaths. Pediatrics, 104(5): 1158-1160, 1999.

6. Luallen JJ, Rochat RW, Smith SM, O'Neil J, Rogers MY, Bolen JC. Child fatality review in Georgia: a young system demonstrates its potential for identifying preventable childhood deaths. Southern Medical Journal, 91(5):414-9, 1998.

7. Durfee MJ, Gellert GA, Tilton-Durfee D. Origins and clinical relevance of child death review teams. JAMA 267(23):3172-5, 1992.

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Last modified: 3-August-2000.