Program Contact

Renay Bradley, PhD, MPH
Chief, Epidemiology and Surveillance Section
Injury and Violence Prevention Branch
Center for Healthy Communities
California Department of Public Health
P.O. Box 997377, MS 7214
Sacramento, CA 95899-7377
Email: renay.bradley@cdph.ca.gov

Website:http://www.cdph.ca.gov/programs/Pages/ChildMaltreatmentPrevention.aspx

Program Description

Administration

Currently in California there is no state child death review (CDR) team. The mandate to the Attorney General’s Office for a state team is contingent upon funds being available. The State Child Death Review (CDR) Council was disbanded in 2008 when state funds were cut. Local Child Death Review Teams (CDRTs) have been functioning since the early 1980s, with Los Angeles County starting in 1978. Most California counties continue to maintain CDRTs, however they are formally authorized (not mandated) in statute (Penal Code §11174.32 Section). A loose network of regional CDRT coordinators exists to maintain communication among local CDRTs and state agencies. The California Department of Public Health (CDPH) created the Fatal Child Abuse and Neglect Surveillance (FCANS) Program in 2000 to carry out its mandate to track data on fatal child abuse and neglect (Penal Code §11174.34 Section). General funds for this program were cut in 2008. However, funding is provided for local assistance under the federal Maternal Child Adolescent Health Title V Block Grant. Approximately $150,000 local assistance money is used to provide support for local teams.

Teams

Currently, California only has local county teams. The State CDR Council was disbanded in 2008 when state funds were cut. The mandate for a state team is contingent upon funds being available.

State Team Chairperson: N/A

A loose network of regional coordinators continues to exist to maintain communication among local CDRTs and state agencies.

Local Teams:

Based on the limited information available to us, there could be up to 37 active local CDR teams. Meeting schedules vary by team.

Reviews

Most California CDRTs review all sudden, traumatic and/or unexpected child deaths (i.e., Coroner cases), including injury, natural and undetermined deaths. Review selection criteria vary by team. Generally, teams review cases of children that are less than 18 years old.

Purpose

Prevention is the overriding priority, but California’s CDRTs have several objectives: 1) to assist in identifying and investigating potential child maltreatment cases; 2) to assist in protecting siblings and other children; 3) to identify and assist in improving agency and systems problems; and 4) to prevent future child deaths from all causes through identifying the circumstances surrounding child deaths and developing recommendations and effective action.

Data

The FCANS Program adopted the National Center for Child Death Review Case Reporting System for local teams to report to the state. Standardized data reporting forms are completed by local CDRTs for mandated cases and for many other reviewed cases as well. In addition to the local teams using their own data, the state FCANS Program aggregates and manages the statewide data.

Annual Report

California has not produced an annual state report for several years due to budget cuts and a lack of a State Council. Under a new state statute, county teams (if they exist) are required to make available their findings and aggregate data annually. Many county CDRTs now have annual reports that are made available to the general public.

Prevention Initiatives

CDR findings have influenced both state and local policy and program changes in California. Statewide laws on child homicide sentencing, safely surrendered babies, children left alone in cars (Kaitlyn’s Law), and child maltreatment reporting and data collection have been enacted. Local and state policy changes have resulted in residential pool safety barrier laws and zero tolerance for carrying guns on school property. California’s CDR findings have motivated prevention activities including public education on child maltreatment prevention in general, and Shaken Baby prevention specifically, Sudden Unexplained Infant Deaths and promotion of safe sleep environments and practices, teen suicide and motor vehicle crash prevention, perinatal substance exposure and parental substance abuse. Reports to the Consumer Product Safety Commission have led to national actions (e.g., 5 gallon buckets, baby bath seats, & unsafe cribs and beds). Although attribution of impact is difficult, CDRTs have been directly responsible for many of these successful activities.

Protocols

California has a variety of protocols in place addressing death investigations conducted by Coroners/Medical Examiners, Law enforcement and child welfare professionals. California relies on the National CDR Center Program Manual, which it helped to develop, for protocols on CDRT functioning and confidentiality requirements.

Training

The CDPH FCANS Program is working with partners to identify ways to provide support on CDRT functioning, data collection, writing effective recommendations and taking findings to action. Various state departments have funded team training in the past.

Last Updated: May 2021

Tools

Reports

Mortality Statistics

Additional Mortality Statistics can be found at: