CDR Principles

Operating Principles

The Operating Principles of Child Death Review 

  • The death of a child is a community responsibility.
  • A child’s death is a sentinel event that should urge communities to identify other children at risk for illness or injury.
  • A death review requires multidisciplinary participation from the community.
  • A review of case information should be comprehensive and broad.
  • A review should lead to an understanding of risk factors.
  • A review should focus on prevention and should lead to effective recommendations and actions to prevent deaths and to keep children healthy, safe and protected.

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The Purpose of Child Death Review

To conduct a comprehensive, multidisciplinary review of child deaths, to better understand how and why children die, and use the findings to take action that can prevent other deaths and improve the health and safety of children.

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The Objectives of Child Death Review

The objectives of the CDR process are multifaceted and will meet the needs of many different agencies, ranging from the investigation of deaths to their prevention.

1.  Ensure the accurate identification and uniform, consistent reporting of the cause and manner of every child death.

  • Reviews ensure team members are informed of all deaths and thus they are more likely to take actions for investigation, services and prevention.
  • More complete information may help to identify cause and manner.
  • Reviews can lead to modifications of death certificates.

2. Improve communication and linkages among local and state agencies and enhance coordination of efforts.

  • Meeting regularly can improve interagency cooperation and coordination.
  • The benefits of sharing information and clearly understanding agency responsibilities can make the CDR process worthwhile in and of itself.
  • Reviews facilitate valuable cross discipline learning and strategizing.
  • Reviews improve interagency coordination beyond the review meetings.

3. Improve agency responses in the investigation of child deaths.

  • Reviews promote early and more efficient notification of child deaths, facilitating more timely investigations.
  • Sharing information on the type of investigation conducted leads to improved investigation standards.
  • Reviews can identify ways to better conduct and coordinate investigations and resources.
  • Many teams report that new policies and procedures for death investigation have resulted from reviews.

4. Improve agency response to protect siblings and other children in the homes of deceased children. 

  • Reviews can often alert other agencies, such as social services, that other children may be at risk of harm; and they identify gaps in policies that may have prevented the earlier notification to these agencies.

5. Improve criminal investigations and the prosecution of child homicides.

  • Reviews can provide new case information to aid in better identifying intentional acts of violence against children.
  • Reviews may bring a multidisciplinary approach to assist in building a case for adjudication.
  • Reviews can provide a forum for professional education on current findings and trends related to child homicides.

6. Improve delivery of services to children, families, providers and community members.

  • Reviews can identify the need for delivery of services to families and others in a community following a child death.
  • Reviews can facilitate interagency referral protocols to ensure service delivery.

7. Identify specific barriers and system issues involved in the deaths of children.

  • Team members can help agencies identify improvements to policies and practices that may better protect children from harm.

8. Identify significant risk factors and trends in child deaths.

  • Reviews bring a broad ecological perspective to the deaths, thus medical, social, behavioral and environmental risks are identified and more easily addressed.

9. Identify and advocate for needed changes in legislation, policy and practices and expanded efforts in child health and safety to prevent child deaths.

  • Every review should conclude with a discussion of how to prevent a similar death in the future.
  • Reviews are intended to be a catalyst for community action.
  • Teams are not expected to always take the lead, but should identify where and to whom to direct recommendations, then  follow-up to ensure they are being implemented. Solutions can be short-term or long term.

10. Increase public awareness and advocacy for the issues that affect the health and safety of children.

  • When review findings on the risks involved in the deaths of children are presented to the public, opportunities can be identified for education and advocacy.

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