Program Contact

Sara Lewis
Coordinator, State Child Fatality Review Team (SCFRT)
Maternal and Child Health Bureau
Prevention and Health Promotion Administration
Maryland Department of Health
Maternal and Child Health Bureau
201 W. Preston St., Room 309
Baltimore, MD 21201
Phone: 410-767-5824
Fax: 410-333-5233


Program Description

Maryland Senate Bill 464 created child fatality review, state and local Citizens Review Panels and the state CAN Council. CFR is mandated but not funded. The program was established by statute (Section 5-701 et seq.) in 1999. It is housed out of the Maternal and Child Health Bureau (MCHB), Maryland Department of Health (MDH). There is one employee at the state level. MCHB also administers the Fetal Infant Mortality Review (FIMR) program.

Maryland has both a state and local CFR teams which are mandatory in each county. CFR also serves as one of the three CAPTA Citizen Review Panels, the others being the State Council on Child Abuse and Neglect and the State Board of the Citizen’s Review Board for Children.

State Team Chairperson: Richard Lichenstein, MD
There are 25 members on the Maryland State Child Fatality Review Team. The Governor appoints the members which include 11 citizens with expertise or interest in child safety or welfare, 12 representatives from state agencies and two pediatricians who are members of the American Academy of Pediatrics. Meetings are held quarterly. The State Team created a policy manual of guidelines to assist local teams with the child fatality review process.

Local Teams:
Local CFR teams are mandated to be multi-agency and multi-disciplinary. Maryland has 23 county based review teams and one city team (Baltimore). Teams conduct retrospective/periodic review of cases. Local teams advocate at the local level through such avenues as letters to the editor and recommendations to agencies. They also identify education and training needs at the local level.

In Maryland, local CFR teams review deaths to children ages 0-17. (The State Team only rarely reviews cases.) Local teams may elect to review deaths up to 21 years of age. Teams review all causes of deaths from cases received from the Office of the Chief Medical Examiner (unusual and unexpected deaths).

The purpose of the Maryland CFR Program is prevention of child deaths.

Maryland participates in the electronic data system made available to all states by the National Center for the Prevention and Review of Child Deaths (NCPRCD). Local teams enter data from case reviews directly into the data system so data summaries are easier to obtain.

Annual Report
Maryland CFR produces an annual report – which reviews the efforts, findings and recommendations of the State and local CFR teams. The report is issued to the Governor, the General Assembly and state and local CFR members.

Prevention Initiatives
CFR findings have motivated prevention activities in the areas of motor vehicle crashes, SUIDs, homicides, suicides and natural means.

The State CFR Team conducts an annual meeting to provide training and education to local CFR team leadership. In 2017, the annual meeting covered a wide variety of topics, including a presentation on Data Quality Control and Improvement. Additionally, there was a training exercise titled “Turn the Curve,” which is a results-based accountability exercise that allows groups to work on turning the curve on specific indicators such as child, adult, family and community well-being. The Baltimore City CFR Coordinator led a presentation on Essentials for Childhood. Lastly, Ms. Cheri Wilson; a nationally recognized diversity and inclusion, cultural and linguistic competence, and health equity subject matter expert, gave an in-depth presentation on intrinsic bias.

In February 2018, the State CFR Coordinator began quarterly calls with local teams. These calls will be used to assess potential technical assistance needs and develop quality assurance protocols.

Last Updated: July 2019