Coordinator: Steve Wirtz, Ph.D.
Chief, Injury Surveillance and Epidemiology Section
Safe and Active Communities (SAC) Branch
California Department of Public Health
P.O. Box 997377
Sacramento, CA 95899-7377
Phone: (916) 552-9831
Fax: (916) 552-9810
Currently in California there is no state child death review (CDR) team. The mandate to the Attorney General’ 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.
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 – (Informal co-chairs – Lisa Frazer, San Luis Obispo County and Greg Wyatt, Sacramento County)
A loose network of regional coordinators continues to exist to maintain communication among local CDRTs and state agencies.
There are 50-55 local CDR teams active at any time. Meeting schedules vary by team
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.
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.
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 moany 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. When possible, the FCANS Program conducts a Reconciliation Audit to better identify and accurately count child maltreatment-related deaths. The Audit is based on multiple state (i.e., Vital Statistics, Supplemental Homicide Reports, Child Abuse Central Index, Child Welfare Services/Case Management System) and local (i.e., CDRT) data sources,using CDRTs as the “alloy” standard (i.e., not a gold standard, but the best standard available based on local CDR and multiple sources). An Audit was last completed for the calendar years 2007-2009. Findings confirm the previously Audit results that the process of using CDRTs to reconcile multiple data sources identifies a significantly higher number of child maltreatment-related deaths than any single state data source.
For several years this Reconciliation Audit number was reported to the National Child Abuse and Neglect Data System (NCANDS) as part of the California Department of Social Services’ (CDSS) annual report. Since 2010 CDSS has been reporting child maltreatment fatality numbers based on the new reporting system mandated under recent legislation SB 39 (Statute Chapter 468, 2007) See the CDSS website for a description of how this system has been implemented.
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.
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.
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.
The CDPH FCANS Program continues to provide training 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: February 2014