Spotlight – Vermont

Elizabeth A. Bundock, MD., Ph.D.
Deputy Chief Medical Examiner
Office of the Chief Medical Examiner
111 Colchester Ave.
Burlington, VT 05401
Phone: 802-863-7320
Email: Elizabeth.Bundock@vermont.gov

Program Description

Administration
The Vermont Child Fatality Review Team was fully authorized in state statute in Spring, 2018. Between 2001 and October 2017, the coordination of the committee was provided by an in-kind faculty member of the University of Vermont. Beginning in November 2018, the Deputy Chief Medical Examiner for the State has coordinated the committee as an elected Chair.

Teams
Vermont has one state-wide team to review child deaths birth through age 17.

State Team:
There is one statewide team that meets monthly to review recent deaths and to conduct other business. The team, consisting of approximately fifteen members, is empaneled under state statute by the Commissioner of Health. Members, as authorized in the 2018 legislation, are from such organizations as the Department for Children and Families, the Department of Health, the Agency of Education, University of Vermont, the University of Vermont Medical Center (the state’s only tertiary medical center), Vermont State Police, Attorney General’s Office, two pediatricians, the Vermont Citizen’s Advisory Board, etc. All unexpected child deaths birth through age 17 in Vermont are reviewed by the full committee.

Reviews
The State Team conducts reviews of every child death (ages birth through 17 years) from unnatural or unexpected circumstances, ie; those from injury, suicide or homicide, etc. Information is obtained from the State Office of the Chief Medical Examiner reports, police reports, child protective services files, etc.

Purpose
To review statistical data and individual cases of child death to identify patterns, trends, and possible predictors of child deaths. To identify social/health/judicial systems strengths and weaknesses as they impact on child fatalities. To develop and recommend changes in procedures, resources, and service delivery systems that impact children and families. To influence the development of policies and laws regarding children and families.

Data
Data for review purposes is obtained from the Office of the Chief Medical Examiner, vital statistics, police reports, and other sources as appropriate. The 2018 legislation authorized legal authority to request records as needed for the case reviews.

Annual Report
Historically, the annual report has provided a summary of the yearly activities and the cases reviewed. Provides a series of recommendations for systems change either locally or statewide which are designed to prevent future child death, injury, or abuse. Recommendations are formulated from the findings of the death reviews performed during the previous year. The report contains a summary of statistics describing the number and nature of all child deaths (birth through 17) from the previous year. The report has not been produced annually due to lack of capacity because of the volunteer status of the team members. In 2007, a data report was prepared and an updated data report was published in 2018. Plans are for a full report with analysis and recommendations to be published in 2020.

Protocols
The State Team meets monthly to review child deaths, create recommendations and conduct other business. Cases are prepared from the OCME although referrals may be received from the local Child Protection Teams, child health and welfare agencies, or individual team members.

Training
Support for attendance at the annual New England Region 1 conference is provided. Members also attend trainings via their individual work situations and share learning with team members.

Last Updated: February 2019