Program Contact

Bunny Carl Matsuura APRN MPH PhD
Hawaii Child Death Review Nurse Consultant
Hawaii Department of Health, Maternal and Child Health Branch
Child Death Review
741-A Sunset Avenue, Room 109
Honolulu, HI 96816
Phone: 808-733-9024
Fax: 808-733-9032

Program Description

In 1997, HRS 321, part 27 established the Child Death Review Program giving the Department of Health authority to conduct multidisciplinary and multiagency reviews of child deaths in order to reduce the incidence of preventable child deaths. The Department of Health and the Department of Human Services provide federal and state funds to staff the program. The Maternal Child Health Branch of the Hawaii Department of Health administers the CDR system. Emergency Services and Injury Prevention Services Branch is an active partner on the State CDR Council as well as local teams, and uses CDR findings to prioritize initiatives.

State Team: (Chairperson Kimberly Arakaki; Medical Consultant, Louise Kido Iwaishi, MD)
The State CDR Council is comprised of 20 agencies and meets quarterly. The Council does not review cases.

Local Teams:
The Local CDR Teams consist of five teams, representing Kauai, Big Island, Maui, Oahu and Military and meet as needed.

Local CDR Teams conduct retrospective reviews of preventable deaths of children who are younger than 18 years old for deaths that occur in the state, according to established criteria for review.

The main purpose of the Hawaii CDR program is to prevent deaths.

The Hawaii CDR program has access to state vital statistics data for all child death cases. Vital statistics data is entered for all deaths to the National Fatality Review Case Reporting System. Standardized “CDR Case Report” forms are completed for deaths that receive a comprehensive local team review. The CDR Council Data Committee analyzes the data with Department of Health staff support.

Hawaii’s CDR Program has access to select state vital statistics. Vital statistics are used to generate a list of deaths annually and provides birth information for children less than three years of age.

Annual Report
Hawaii has produced three reports: the first was for the pilot period of 1996 and Summary reports for 1997-2000 and 2001-2006. The most recent summary report is available on the State of Hawaii website. Annual reports are currently required by the legislature and have been submitted in 2016 and 2017.

Prevention Initiatives
CDR prevention partners include Safe Sleep Hawaii, Keiki Injury Prevention Coalition (KIPC), Hawaii Suicide Prevention Task Force, DOH Injury Prevention and Control Program (IPCP) and others. For example, a Safe Sleep education campaign was initiated. Additionally, a suicide task force, under IPCP, has a state plan.

A Child Death Review Policy and Procedure Manual.

Previously, through the generosity of the Federal Community-Based Child Abuse Prevention grant and the National Center for the Review and Prevention of Child Death, Coordinated Infant Death Investigation training was provided in 2011 to promote a multi-disciplinary approach to death investigations. Stakeholders from the State of Hawaii, including City and County of Honolulu Medical Examiner staff, emergency medical personnel, law enforcement officials, child welfare workers, CDR members, and a representative from the Hawaii Safe Sleep Committee attended the training. Although CDR teams do not act as investigative bodies, team members apply best practices from the respective agency. This training helped to standardize the investigative and CDR process. CDR training was provided by the National Center in 2016 to all CDR teams.

Last Updated: February 2018