Program Contact

Kate Jankovsky, MPH, MSW
Child Fatality Prevention System Manager
Colorado Department of Public Health and Environment
4300 Cherry Creek Drive South
Denver, CO 80264-1530
Phone: 303-692-2947
Fax: 303-691-7901


Program Description

Colorado has conducted child fatality reviews at the state level since 1989 through an interagency agreement between the Colorado Department of Human Services and the Colorado Department of Public Health and Environment (CDPHE). The Colorado Child Fatality Prevention System (CFPS) was codified in statute in 2005 (Colorado Revised Statute Article 20.5 of Title 25), which housed the system at CDPHE Prevention Services Division’s Violence and Injury Prevention – Mental Health Promotion Branch.

The 2005 statute created a multidisciplinary and multi-agency State Review Team and required the team members to review all preventable fatalities of children ages 0-17 that occur in the state of Colorado. This public health review process is conducted to identify trends across a variety of child fatality causes and make prevention recommendations for the future.

Though previously funded through MCH Block and CAPTA federal funds, the statute received appropriation during 2013 legislative session to support comprehensive reviews of fatalities of infants, children and youth at the local level. Updates to the statute in 2013 transitioned the reviews to the local level and requires local public health agencies to establish or arrange for the establishment of a local, multidisciplinary child fatality review team. CDPHE CFPS support staff provide oversight, funding, and comprehensive technical assistance to the local child fatality prevention review teams.

The Colorado CFPS State Review Team is a volunteer, multidisciplinary committee comprised of 46 members who work collaboratively to review deaths of children less than 18 years of age. Members of the State Review Team are experts in the fields of child abuse prevention, pediatrics, family law, death investigation, motor vehicle safety and sudden infant death syndrome (SIDS)/sudden unexpected infant death (SUID). The state team meets quarterly to discuss case review findings, prevention recommendations, and policy issues.

Currently, 43 local, multidisciplinary child fatality review teams have formed representing all 64 Colorado counties. These teams are responsible for conducting comprehensive review of child fatalities and implementing child fatality prevention efforts.

Local review teams are responsible for conducting individual, case-specific review of fatalities of children from 0-17 years of age occurring in the coroner jurisdiction of the local review team for the purpose of identifying prevention recommendations. Local teams review the following types of deaths: sudden unexpected infant deaths/SIDS, accidents/injuries (drownings, falls, poisonings, fires, suicide, homicide, firearm deaths), child abuse and neglect, motor vehicle incidents, and any natural deaths with an indication of preventability.

Colorado utilizes a public health approach in the review of child fatalities for the purpose of prevention. The fatality review process is not investigative.

Standardized data reporting forms are completed for all reviews. State vital records are utilized for case identification and demographic analysis. In 2009, the CFPS State Review Team began using the National Center for Fatality Review and Prevention Case Reporting System to capture circumstances and prevention recommendations. This system currently contains complete data on child deaths reviewed from 2004-2017.

Local review teams are required to use the National Center for Fatality Review and Prevention Case Reporting System. On an annual basis, data analysis are completed to review aggregated trends and patterns to develop legislative reports, data briefs, local team data reports and updates to the CFPS Data Dashboard..

Annual Report
Colorado does not produce an annual report. The program has previously produced data reports and statistical briefs based on multiple years of findings and specific topical areas when funding was available.

The CFPS State Review Team is mandated to develop a legislative report to make any recommendations for changes to law, rule or policy that the team has determined will promote the safety and well-being of children in Colorado. This report is produced on an annual basis for the Governor and the General Assembly of Colorado.

Prevention Initiatives
CFPS findings have influenced policy changes in Colorado. Recommendations by the review members have enacted statewide changes in policies, procedures and communication within state agencies and among local agencies that work with children and families. Fatality review findings have also motivated prevention activities in Colorado, such as the development of child passenger safety seat promotion programs, increase in seat belt usage and awareness, creation of graduated licensing law restrictions, a public awareness campaign on bucket drowning prevention, pilot testing a means restriction education program in hospital emergency departments, and promotion of infant safe sleep within licensed child care centers and homes.

Colorado has a confidentiality protocol in place. In addition, the CFPS support staff has developed the Colorado Child Fatality Prevention System: An Introduction to the System which provides procedures and protocols for local child fatality prevention review teams.


The CFPS support staff at CDPHE provide technical assistance and training to local child fatality prevention review teams to ensure they conduct effective child fatality reviews and develop as well as implement actionable prevention recommendations.

Last Updated: January 2019