Program Contact

Kate Jankovsky, MPH, MSW
Child Fatality Prevention System Manager
Colorado Department of Public Health and Environment
4300 Cherry Creek Drive South
Denver, CO 80264-1530
Phone: 303-692-2947
Fax: 303-691-7901
Email: kate.jankovsky@state.co.us

Website:http://www.cochildfatalityprevention.com/

Program Description

Administration
Colorado has conducted child fatality reviews at the state level since 1989 through an interagency agreement between the Colorado Department of Human Services and the Colorado Department of Public Health and Environment (CDPHE). The Colorado Child Fatality Prevention System (CFPS) was codified in statute in 2005 (Colorado Revised Statute Article 20.5 of Title 25), which housed the system at CDPHE Prevention Services Division’s Violence and Injury Prevention – Mental Health Promotion Branch.

This public health review process is conducted to identify trends across a variety of child fatality causes and make prevention recommendations to prevent deaths from occurring in the future.

Though previously funded through MCH Block and CAPTA federal funds, the statute received appropriation during 2013 legislative session to support comprehensive reviews of fatalities of infants, children and youth at the local level. Updates to the statute in 2013 transitioned the reviews to the local level and requires local public health agencies to establish or arrange for the establishment of a local, multidisciplinary child fatality review team. CDPHE CFPS support staff provide oversight, funding, and comprehensive technical assistance to the local child fatality prevention review teams.

Teams
The Colorado CFPS consists of : 1) the State Review Team- a volunteer, multidisciplinary committee comprised of child fatality prevention and child and family wellbeing experts  who work collaboratively to review aggregated data on the deaths of children less than 18 years of age, and make prevention recommendations to prevent future deaths. The recommendations are compiled annually in a legislative report, submitted to the Colorado General Assembly every July 1st. The state team meets quarterly to discuss case review findings, prevention recommendations, and policy issues; and 2) the local child fatality prevention review reams – multidisciplinary teams representing a single or multiple counties in all of Colorado’s 64 counties that are charged with the review of child deaths in their jurisdiction. These local teams reflect the unique culture and expertise of the communities they represent. They not only review cases implement child fatality prevention efforts locally.

Reviews
Local review teams are responsible for conducting individual, case-specific review of deaths of children from 0-17 years of age occurring in the coroner jurisdiction of the local team for the purpose of identifying prevention recommendations. Local teams review the following types of deaths: sudden unexpected infant deaths, injuries (drownings, falls, poisonings, fires), suicide, homicide, firearm deaths, child abuse and neglect, motor vehicle and other transportation incidents, deaths due to undetermined causes, and any natural deaths with an indication of preventability.

Purpose
Colorado uses a public health approach in the review of child fatalities for the purpose of prevention. The fatality review process is not investigative, and there are no legal (civil or criminal) outcomes of the review. The system also partners with other family wellbeing partners and initiatives across the state to support infants, children, youth, and families thriving in Colorado.

Data
Colorado uses the National Center for Fatality Review and Prevention’s Case Reporting System to collect information from case reviews. State vital records are used for case identification and demographic analysis. This system currently shares data on child deaths reviewed from 2009-2018 on the CFPS Data Dashboard.

Local review teams are required to use the National Center for Fatality Review and Prevention Case Reporting System. On an annual basis, data analysis are completed to review aggregated trends and patterns to develop legislative reports, data briefs, local team data reports and updates to the CFPS Data Dashboard – providing counts, rate, and circumstance data on the leading causes and circumstances of death across Colorado: child and youth suicide, child maltreatment deaths, sudden unexpected infant deaths, motor vehicle and other transportation deaths, firearm deaths, unintentional drowning deaths, and unintentional poisoning or overdose deaths for the state and by county.

Annual Report
Per statute, Colorado produces an annual legislative report. The CFPS State Review Team is mandated to develop a legislative report to make any recommendations for changes to law, rule or policy that the team has determined will promote the safety and well-being of children in Colorado. This report is produced on an annual basis for the Governor and the General Assembly of Colorado.
The program also produces several types of data reports include cause of death-specific data briefs on the leading causes of death impacting people under 18 in Colorado as well as data reports that explore topics in more detail. Links to these reports can be found in the Reports section.

Prevention Initiatives
CFPS findings have influenced policy changes in Colorado. Recommendations by the review team members have enacted statewide changes in policies, procedures and communication within state agencies and among local agencies that work with children and families. Fatality review findings have also motivated prevention activities in Colorado, such as the development of child passenger safety seat promotion programs, increase in seat belt usage and awareness, creation of graduated licensing law restrictions, a public awareness campaign on bucket drowning prevention, pilot testing a means restriction education program in hospital emergency departments, promotion of infant safe sleep within licensed child care centers and homes, and supporting access to public assistance programs to prevent child maltreatment.

Protocols
Colorado has a confidentiality protocol in place. In addition, the CFPS support staff has developed the Colorado Child Fatality Prevention System: An Introduction to the System which provides procedures and protocols for local child fatality prevention review teams.

Training
The CFPS support staff at CDPHE provide technical assistance and training to local child fatality prevention review teams to ensure they conduct effective child fatality reviews and develop as well as implement actionable prevention recommendations. Local teams also convene annually for training and support at the Shared Risk and Protective Factors Conference – a conference designed for youth, community members, and professionals working in violence and injury prevention across Colorado.

Last Updated: May 2021