Program Contact

Kacy Robinson
Utah Department of Health
Violence and Injury Prevention Program
P.O. Box 142106
Salt Lake City, UT 84114-2106
Phone: 435-720-3512 (mobile)

Email: kacymr@utah.gov

Website: http://www.health.utah.gov/vipp/childFatality/overview.html

Program Description

Administration
Child Fatality Review Committee:
Each year around 470 children ages 0-18 die in Utah. In response to these deaths, a few different interagency Child Fatality Review Committees (CFRC) have established by the Utah Department of Health. The first beginning in 1992. The CFRC was charged with the review of the circumstances and cause of all childhood deaths in the state. The purpose of the CFRC is to develop a better understanding of child deaths in order to reduce the number of intentional and unintentional deaths of Utah children.

The goals of the CFRC are to:

  • Identify and describe the prevalence of risk factors among deceased children by studying and reporting trends and patterns of child deaths in Utah.
  • Maximize resources through interagency collaboration to identify and describe the service delivery of the involved systems (medical, human services, and law enforcement) to high-risk children, and make policy recommendations to improve the service systems to better meet the needs of all families involved with these systems.
  • Promote effective prevention strategies to reduce the number of child deaths.
  • Refer issues and propose strategies to appropriate organizations and agencies to promote education and prevention.

The main CFRC meets once a month to review Utah child deaths from injury related and undetermined causes. These include accidental deaths, homicides, undetermined deaths, as well as any Sudden Unexpected Infant Death (SUID) or Sudden Death in the Young (SDY) deaths.
There is also a separate quarterly review process that focuses on Utah’s youth suicide deaths. This Suicide Child Fatality Review Committee (SCFRC) which includes most of the same committee members as the CFRC was added in 2020 to address the large amount of time being spent each month on youth suicide death, because of the high number and all of the additional information available from the psychological autopsies/next of kin interviews that are done on these cases.

After the initial CFRC review of any SUID/SDY deaths, there is also a quarterly Advanced Clinical Review Committee (ACRC) with a diverse group of pediatric medical experts including neurologists, forensic pathologists, cardiologists, and geneticists/genetic counselors who categorize them and address potential pathologies and genetic issues identified.

Each of these death review processes provide a detailed understanding of how and why child deaths occur in Utah and discuss recommendations prevent future death and injury. The goals of the reviews are to:

  • Identify the important issues and concerns surrounding the deaths.
  • Assess the accuracy and completeness of data from death investigations.
  • Assess the accuracy and completeness of medical data surrounding the deaths.
  • Improve communication through interagency collaboration of the various health, human services, and law enforcement agencies to ensure that complete and thorough investigations are performed on child deaths.
  • Refer prevention and policy recommendations to the Child Fatality Action Committee (This committee brings together partners working in prevention from across the state and CFRC members annually to review the recommendations and the aggerate and trend data to identify priories that should be addressed in the state.).

The formation of the different child fatality review committees brings together diverse agencies and organizations that serve Utah children and families. This multidisciplinary approach enables members to share available information from different sources to better understand how and why a child has died. It also helps them understand how their organization can help prevent future death and injury. It is this coordination that improves the process of thoroughly reviewing child deaths and the implementation of prevention recommendations in Utah.

Teams

State Team:(Chairperson – Kacy Robinson)
This team has 34 members. The team meets monthly.

State Suicide CFRC Team:(Chairperson – Michael Staley)
This team has 17 members. The team meets sixteen times a year. The Advisory Committee meets yearly.

State Advanced Clinical Review Committee:(Chairperson – Kacy Robinson)
This team has 20 members. The team meets quarterly.

State Action Committee:(Chairperson – Nathan Malan)
This team has 24 members. The team meets monthly.

Reviews
The Utah State Team conducts a full review on all suspicious, unexplained or unexpected deaths. Additionally, all injury deaths receive a committee review and all death certificates receive a medical review. The team reviews deaths to children age 18 and under.

Purpose
The purpose of the Utah Child Fatality Committee is to investigate child deaths and provide quality assurance and services in order to improve response and prevent future child deaths.

Data
Beginning in 2014, death data is being submitted to the National Center for the Review and Prevention of Child Deaths (NCRPCD). The Department of Health has access to the Office of the Medical Examiner database and the state vital records. These are used on each case to identify data as well obtain information for collection. The Department of Health analyzes the data with SAS.

Annual Report
The Utah Child Fatality Committee produces an annual report. This is distributed to the Child Fatality Committee, local health departments, health department officials, the media, hospitals, libraries and is available on the VIPP website. Fact Sheets are published periodically to inform the public on specific topics in the interim.

Prevention Initiatives
Findings from the review process have influenced policy changes in Utah. These include seat belt/car seat/booster seat legislation, the initiation of a youth suicide study, dating violence protections, among others. Additionally, child fatality review findings have motivated prevention efforts.

Protocols
Utah has several protocols in place including protocols for the CFRC meetings, confidentiality, child/infant death scene investigation and a death certificate review process.

Training
Training is offered as new people join the different committees and as evaluation indicated specific needs or changes to processes.

Last Updated: May 2022

Tools

Reports

Mortality Statistics