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Infant and Child Death Review: A New Avenue for Forensic Nurses

Submitted by Author Pamela D. Tabor, DNP, Forensic Certification, WHNP-BC, SANE-A

On The Edge – 2011

One gauge on national health is the infant and child mortality rate in the United States (O’Neal, 2007).  To decrease infant and child mortality rates the American Bar Association, in 1995, led the way to the training curriculum for Child Death Review Program.  Since that time 49 states have formed Infant and Child Death Review Programs at the local level within their states.  Although states vary in how the teams are formulated, team personnel, and cases reviewed the objective is clear: review cases so that preventive measures can be identified and implemented to prevent future infant and child deaths.

Under the guidance of the National Center for Child Death Review there are numerous publications, training materials, forms and handouts to assist in the development and maintenance of state and local teams.  The Director of National Center for Child Death Review is Teri Covington, who is in Washington, DC.  Ms. Covington is available to visit different sites that are trying to establish a state and/or local team to provide one-on-one or group trainings.  Also there is a training manual: A Program Manual for Child Death Review which can be obtained from www.childdeathreview.org.  Further information and support provided by the National Center for Child Death Review includes:

  • The National Child Death Review Program Manual
  • Website with CDR info, mortality data and many resources for teams.
  • Listserv that reaches state CDR coordinators and leaders.
  • CDR Training Curricula
  • Descriptions of the state CDR programs
  • State CDR reports
  • Information on the causes of child deaths
  • Prevention resource materials and links to experts and organizations
  • Links to child death investigation, resources and procedures: www.childdeathreview.org

Additionally examples of Fetal and Infant Mortality Review (FIMR) can be viewed at www.med.jhu.edu/wchpc or www.jhsph.edu/wpch./projects/fimr.html

Teams have been started for various reasons, but predominately they were first established to deal with child abuse and neglect cases.  However, most teams now review unexpected deaths of all children (usually defined as under 18).  Some teams have special committees that deal with a single or selected issue (such as neonatal or abuse cases).  Depending on protocol each state and/or local team establishes what criteria are used to select cases.

The use of a community team is imperative to the review process.  Each county has its own nuances and issues that are best understood by the locals.  Development of multidisciplinary teams (MDT) within that community allows for members that are familiar with their own community and the needs within that community.   Local teams vary in membership but usually include: law enforcement; child protective services; prosecutor/district attorney; medical examiner/coroner; public health representative; pediatrician; and emergency medical personnel.  Other people can be added to reviews if they have pertinent information for a particular review, such as a fire department representative if there was a house fire. 

Currently Arkansas (AR) is in the process of establishing the AR Infant & Child Death Review Program.  Under Act 1818 the AR Child Death Review Panel was established and tasked with initiating infant and child death reviews.  Under the Panel’s prevue a state team has been established with a director and coordinator to help local teams establish themselves within their own communities.  The Arkansas Infant & Child Death Review Standard Operating Procedure Manual is in print and two pilot teams have been selected to begin the review process in their respective community.  The state team will assess local team reviews; track infant and child mortality trends; provide support and guidance to local teams; and assist in preventative measures.

In AR each local team has a director that serves as the administrator and is responsible for the flow and functioning of the team and is responsible for the signing of interagency agreements and confidentiality agreements. Additionally a coordinator is elected by the team to serve as the source of baseline case information obtained from death certificates, organizes and plans the meeting, completes a team tracking form to keep track of the cases and actions taken on each case.  Additionally the coordinator enters the data into: The Child Death Review Case Reporting System.  Team members are responsible for bringing the records from their respective agency that pertains to the case(s) under review.  The members should bring their own information and leave with their own information without making any copies for other members.  This will ensure confidentiality of agency records.

Team meetings generally begin with the reminder and signing of the confidentiality agreement.  Then each case is reviewed individually, which is usually best accomplished through establishing a timeline of the infant/child’s death.  Beginning with the first responder and moving through the medical care and autopsy, as well as filling in the social and medical history.

According to the National Child Death Review process:

“The individual case report [The Child Death Review Case Reporting System] is completed on all deaths reviewed by a team. It should include information on the child, caregivers, supervisors, circumstances of the event leading to the death and team findings related to services and prevention. When completed following case reviews, tabulations of and analysis of the data from the case reports will provide:

  • Comprehensive information on the child, family and supervisor.
  • Risk factors in the child deaths reviewed.
  • Descriptions of the investigation activities conducted as a result of this death.
  • Descriptions of the services provided or needed as a result of the deaths reviewed, and the review teams recommendations for new services or referrals.
  • The team’s recommendations and actions taken for the prevention of other deaths.
  • Factors affecting the quality of the case review meetings”.
    www.childdeathreview.org.

Infant & Child Death Review is a rich avenue for forensic nurses.  Obviously those with an interest in death investigation would be the logical choice.  However, forensic nurses with experience in pediatrics can provide wonderful insight into developmental milestones and age-appropriate activities.  Forensic nurses that are involved in intimate partner violence can have unique input as well.  According to The World Health Organization (2003) “the risk of death in infancy or before 5 years of age was more than six times greater if the mother had been exposed to both physical and sexual violence by a current or former partner at any point in her life, even after adjusting for educational, parity, area of residency, and basic needs assessment level” Additionally, physical violence is associated with an increased risk of antepartum hemorrhage intrauterine growth restriction and perinatal. To conduct 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 of children.

In a nutshell the goal of infant and child death review is to conduct a comprehensive, multidisciplinary review of infant and child deaths, to better understand how and why infants and children die, and use the findings to take action that can prevent other deaths and improve the health and safety of children www.childdeathreview.org.

A simple child, That lightly
draws its breath,
And feels its life in every limb,
What should it know of death?

Wm. Wordsworth

References

Pamela Tabor has a Doctorate of Nursing Practice, an Advanced Health Specialty Certification in Forensics, is a Woman’s Health Nurse Practitioner (WHNP-BC)  and is a sexual assault nurse examiner for adults/adolescents (SANE-A).  Dr. Tabor is employed as the first Director of Arkansas Infant & Child Death Review Program.  Additionally she serves on the Arkansas Child Death Review Panel and the Department of Children and Family Services (DCFS) external committee for review of fatality cases involving children and siblings in the care of DCFS.

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