Program Contact

Xun Shen, MD, MPH
Interim CDR Coordinator
Oregon Health Authority, Injury and Violence Prevention Program
800 NE Oregon Street, Suite 730
Portland, OR 97232
Phone: 971-673-1098
Fax: 971-673-0990

Program Description

The Oregon State Child Fatality Review Team was established in 1989. In 1991, county level child fatality review processes were established. In order to provide technical assistance to these local teams, the legislature established the State Technical Assistance Team (STAT) in 1995 which was housed in the Injury and Violence Prevention Program in Public Health. Funding for this team was eliminated in 2000. Funding for counties goes to District Attorney Offices who operate multidisciplinary teams (MDT) for the investigation of child abuse. The statute that established the MDT requires these teams to set up a CFR process. Funding for the MDT activities also covers the CFR work but it is not funding directed to CFR activities. The amount of funding to the local communities varies. CFR activities are an add on to the MDT statute. There are team members who conduct CFR activities as part of their job responsibilities.

Oregon has both state and local CFR teams.

State Team Chairperson(s): Michele Stauffenberg, MD, State Medical Examiner and Deborah Carnaghi, LCSW, State Child Protective Service Program Manager
The Oregon State Child Fatality Review Team has 20 members that meet twice a year. The purpose of their meetings is to make recommendations and take actions involving statewide child fatality issues.

Local Teams:
District attorney offices chair local teams in Oregon. There are 36 teams in Oregon, each consisting of approximately ten members. Teams are made up of representatives from at least five key agencies: law enforcement, the district attorney, child protective services, public health and the medical examiner. In many counties, representatives from Emergency Medical Services, Victims Assistance Programs, Juvenile Justice, Fire Department, Schools and local health care providers participate in the process. Teams conduct retrospective/periodic reviews.

Teams review unexpected deaths including homicides, suicides, accidents, unexpected natural deaths and deaths due to an undetermined manner to children less than age 18.

The purpose of CFR in Oregon is investigation, prevention, quality assurance, data collection and to provide services. This is the focus in statute. There is a shift on the state level to primarily a prevention focus. The local teams also work on prevention.

Oregon began participating in the National Child Death Review Data System in 2013. Cases beginning 1/1/14 were entered into this system. Local teams can contact the IVPP staff, their local health department or the Center for Health Statistics to request copies of death certificates. Staff also use vital records to create lists of cases that should be reviewed and provide them to the local District Attorney’s office when requested to assure that cases are identified and reviewed.

Annual Report
Annual reports on child death due to violence, maltreatment, suicide and injury are produced as part of an annual injury report that is produced by the injury epidemiologist. The report includes recommendations for prevention and policy and is linked to the five year state prevention plan.

Prevention Initiatives
CFR findings have influenced policy changes on the state level. There was a change in the child abuse statutes to eliminate the religious beliefs exemptions for homicide cases. Statutes to prohibit children from riding in the back of pickup trucks, requiring helmets when skating, riding scooters and skate boards, booster seat requirements and the prohibition of the resale of older cribs that are dangerous in second hand stores have been passed. Statute was passed to outlaw toy lighters and mandate fire safe cigarettes. Additionally, prevention information is provided to all new parents through the state newborn handbook including information on safe sleep environment, home safety, and child passenger safety. CFR findings have also implemented prevention initiatives at the local level. Examples include: The state developed a suicide prevention plan that is being implemented by local groups. Oregon coastal communities implemented a prevention program to reduce the number of deaths due to logs rolling over kids playing on driftwood. Clackamas County established a lifeguard at two public swimming beaches on the Sandy River. Safe Kids coalition continue to partner with local teams to distribute helmets and safety seats to low income families with children. A window falls prevention alliance has developed a communications strategy to prevent window fall injuries among children.

Oregon CFR has meeting, confidentiality and child/infant death investigation protocols in place.

Training on the CFR process is presented by DOJ staff for Victim’s Assistance staff working for local DAs. Training on using the national data entry system was provided to local teams in 2013.

Last Updated: February 2019