Child Death Review (CDR) is a prevention-oriented process that reviews the circumstances surrounding the death of a child to improve the health and safety of the community. This page contains key materials for understanding CDR principles, models, confidentiality, roles of team members and provides guidance on conducting effective review meetings.

I. The Operating Principles of Child Death Review 

A child’s death is a community tragedy and responsibility does not rest in any one place. The death of a child is a sentinel event that should catalyze action. Fatality review teams are diverse, multidisciplinary groups of professionals who come together to understand the complex, multifaceted factors surrounding the death of a child. In short, CDR teams seek to understand the “how” and “why” surrounding the death to prevent future deaths.

The objectives of the CDR process are broad and will meet the needs of many different agencies, ranging from the investigation of deaths to their prevention. Learn more about the 10 primary CDR objectives.

II. CDR models
Child death review programs typically will fit one of four different models. The models vary by what core functions they perform, by whether reviews are conducted at the state or local level, by the types of deaths they review, and by where team authority lies.

Local-only reviews of individual cases, state reviews of local findings, and state and local responses to findings.

A state agency provides oversight and coordination to a network of local review teams. The state provides protocols or guidelines for local reviews, with varying degrees of authority. States usually provide training and technical assistance to their local team members and have a state CDR coordinator staff position.

Most reviews are conducted at the local level and recommendations are made for improvements to local policies and practices. Prevention initiatives are implemented locally. Local review teams may serve county, city, and/or regional jurisdictions, and the agency coordinating the local teams varies. These teams usually submit case review reports to a state agency or state CDR program office. Then a state advisory team reviews the aggregate or individual findings of local teams and makes recommendations for improvements to state policies and practices. Most states using this method produce an annual report with child mortality data, CDR findings, and recommendations. States utilizing this approach may focus on child abuse deaths or on all preventable deaths.

States vary as to whether local teams receive funding for reviews, but in all but a few states, they do not. States also vary in whether local reviews are mandated or are voluntary. Teams may also have sub-committees reviewing specific causes of deaths and report these findings to their local or state CDR team.

Most review meetings are held as Retrospective Reviews. These usually take place after the investigation is mostly completed and case information is readily available. Some teams have Immediate Response Reviews that typically occur shortly after a death, usually of those that are unexpected or unexplained. Using this method, the team is able to discuss case information immediately, thereby affecting the processes and procedures used during the active investigation of a child death. This type of review may also assist protective services in their work to protect other children involved. Because immediate response review meetings are unscheduled, the team coordinator usually contacts each team member to arrange these reviews. Teams should establish criteria to identify deaths that require immediate response reviews. Often only a select sub-group of the full team will participate in these types of reviews. If a team chooses an immediate response review but has standing meeting dates for retrospective reviews as well, then it is likely that the case will go through both types of review. In this way, the CDR process acts as a tool for coordinating death investigations and delivery of services, as well as a source of information for identification of risk factors and prevention of other deaths in the future.

State and local review of individual cases and state and local response to findings

A state-level committee reviews certain types of deaths or a representative sample of cases, while local teams review cases independent of the state team. There may be little or no coordination between the local and state reviews or the state may review the local findings. The local review teams may not operate under mandated or suggested state guidelines. Local teams rarely receive state funds for their reviews. As with the other approaches, the agency lead varies by jurisdiction.

State-only reviews of individual cases and state-level responses to findings.

A state-level CDR committee reviews child death cases and issues a state-level report of findings, and no community reviews take place. These review panels usually involve state agency representatives. Most state-level reviews started as child abuse reviews, but some have expanded into other preventable causes of death. In several states, comprehensive case records are made available to an abstractor who prepares the case for the review team. In other states, agencies bring their own records to the review.  The types and numbers of deaths reviewed usually represent only a proportion of all deaths in the state.

A variation of this model is that a state agency may have an internal review team comprised of their own agency representatives. In this model, the deaths reviewed are usually of children that were in the care and custody of that agency, for example, deaths of children in foster care. The state committee may also serve as the state’s Child Abuse Prevention and Treatment Act (CAPTA) mandated Citizens Review Panel (CRP) and conduct case reviews or review local case reviews of child abuse deaths.

Local only review of individual cases and local response to findings.

These teams operate independently of the state, although in some cases a state-level person may help to bring some of the teams together for training and/or technical assistance. Reviews are conducted in city or county jurisdictions. Some teams issue written reports of their findings.

III. Confidentiality
Confidentiality is an important issue when discussing the implementation or continuing work of a Child Death Review (CDR) team. Sensitive information is the currency of CDR teams. They collect sensitive information from their members and others, and they compile sensitive information through their activities. Review team members are not the only ones interested in the information. Child deaths are often in the public eye and may be controversial. The public and the press may want to know what the team knows. Learn more about the team’s access to information, the public’s access to information, a four-part approach to confidentiality, and other confidentiality measures teams can implement.

Confidentiality Statement (Word)) (PDF)

IV. Roles of team members
Core members of CDR teams are responsible for responding to child deaths or for protecting children’s health or safety. A CDR team should always have representatives from law enforcement, child protective services, prosecutor/district attorney, medical examiner/coroner, pediatrician or other health provider, public health, and emergency medical services. Additional and ad hoc members from other agencies, providers and professions involved in protecting children’s safety and health should be considered for CDR team membership and certainly provisions should be made for their inclusion on a case appropriate basis. Periodically, CDR teams may consider inviting individuals with expertise to participate in a specific review or to brief the team members about their expertise.
All team members should contribute information from their records, explain agency best-practices and professional obligations, identify potential prevention opportunities and maintain confidentiality agreements.

Roles of team members (Word)

V. Conducting effective meetings
There are different approaches used by teams around the country to conduct death reviews. But there are certain basic steps that if followed, will help lead to complete and thorough reviews that address the maximum number of issues involved in children’s deaths while focusing the team on prevention. Learn more about the six steps for effective reviews.

Conducting Effective Meetings (Word)

A Program Manual for Child Death Review which was prepared by The National Center serves as a primary tool for state and local CDR teams.