Program Contact

Gretchen Martin, MSW
State Child Fatality Review Program Coordinator
Indiana State Department of Health
2 North Meridian Street
Indianapolis, IN 46204
Phone: 317-233-1240
Fax: 317-233-1342


Program Description

On July 1, 2013, a new Indiana law (IC 16-49) went into effect, requiring child fatality review teams in each county, with coordination and support for these teams to be provided by the Indiana State Department of Health (ISDH). Prior to this, the local child fatality review teams fell under the auspices of the Indiana Department of Child Services (DCS) and were required in each of the 18 DCS regions. IC 16-49 also required that a coordinator position be created under the ISDH to help support and coordinate the local teams and Statewide Child Fatality Review Committee–whose members are appointed by the Governor.

The prosecuting attorney in each county is required by this new legislation to establish a Child Fatality Committee whose membership includes: the prosecuting attorney or their representative, the county coroner or deputy coroner, and representatives from the local health department, DCS, and law enforcement. The Child Fatality Committee is responsible for selecting members to serve on the Local Child Fatality Review (CDR) Team and determining whether to establish a county child fatality review team, or enter into an agreement with another county or counties to form a regional child fatality review team.

State Team: The Statewide Child Fatality Review Committee is comprised of 15 members who are appointed by the Governor, and several ad hoc members who serve at the request of the Committee. The Statewide Committee meets monthly, serving as a consulting body to assist the efforts of the local teams and can assist with, or conduct, individual case review at the request of a local team or the DCS Ombudsman.

Local Teams: Indiana has 66 county and regional teams representing 89 of the 92 counties. Each local CFR team will be made up of a coroner/deputy coroner, a pathologist, and pediatrician or family practice physician, and local representatives from law enforcement, the local health department, DCS, emergency medical services, a school district within the region, fire responders, the prosecuting attorney’s office, and the mental-health community.

Local teams are required to review all deaths of children under the age of 18 that are sudden, unexpected or unexplained, all deaths assessed by DCS, and all deaths that are determined to be the result of homicide, suicide, accident, or are undetermined.

The Indiana CFR Program attempts to better understand how and why children die, takes action to prevent injury, disability, and death and improves the health and safety of our children.

Indiana utilizes the Case Reporting System administered by the National Center for the Review and Prevention of Child Deaths. Case report forms are completed for all reviews as required by statute. The Indiana CFR has access to injury data, maternal and child health data, and vital statistics information.

Annual Report
Local teams are required to provide an annual report to the Statewide Child Fatality Review Committee, who will then endeavor to identify trends and inform efforts to implement effective statewide prevention strategies. The Statewide Committee is required to submit an annual report to the Indiana legislative council, Governor, DCS, ISDH, and the Commission on Improving the Status of Children in Indiana.

Prevention Initiatives
Indiana CFR findings have motivated local prevention such as bumper pad /sleep sack exchange programs, infant safe sleep education and crib give-aways, infant safe sleep media campaigns, water safety education, suicide prevention and ATV safety initiatives.

Program and policy changes at the regional and state levels have also been implemented as a result of CFR. Some regional hospitals have stopped using blankets in their labor/delivery and NICU areas to ensure the presentation of a consistent safe sleep message. As a result of case review by the Statewide Committee, legislation was passed requiring ladder locks to be sold with above ground pools to help prevent access by unsupervised children.

Training for the local teams and Statewide Committee is organized by the state CDR program coordinator and local partners.

Last Updated: January 2019