Child fatality review annual report

CHILD FATALITY REVIEW
1991 ANNUAL REPORT GEORGIA STATEWIDE CIDLD FATALITY REVIEW PANEL
JUNE, 1992

STATE CHILD FATALITY REVIEW PANEL

CHAIRMAN:

Robert L. Carmichael Chairman, Board, Department of Human Resources Commercial Bank and Trust Post Office Box 250 La Grange, Georgia 30241

Juanita Carter, F.d.D. Citizen Representative Spelman College Psychometrician/Adjunct Faculty One Georgia Center, Suite 1570 600 West Peachtree Street Atlanta, Georgia 30308

Honorable Donoval Dixon, Jr. (Donny) District A ttomey Waycross Judicial Circuit 201 State Street Waycross, Georgia 31501

Douglas G. Greenwell, Ph.D. Director, Division of Family and Children Ser-vices Department of Human Resources 878 Peachtree Street, N. E. Room 421 Atlanta, Georgia 30309

J. Robbie Hamrick
Director, Georgia Bureau of Investigation
Post Office Box 3 70808 Decatur, Georgia 30037-0808

Honorable Herbert E. Phipps Judge, Dougherty County Juvenile Court Post Office Box 1827 Albany, Georgia 31702

James Q. Whitaker, M.D. Chief Medical Examiner, Houston County Post Office Box 2981 Wamer Robins, Georgia 31099

NOTE: Others who served as panel members during this time are:
Dewitt C. Alfred, Jr., M.D. (past Chairman of Panel; past Chairman of Department of Human Resources Board)
Wayne Phillips, former judge of Juvenile Court, Cobb County

TABLE OF CONTENTS
Executive Summary.............................................................................................. 3 Preface............................................................................................................... 5 llistory of Child Fatality Review........................................................................... 7 The Child Fatality Review Process......................................... 10
Data Analysis..................................................................................................12
Additional Information From Fatality Report31 Implementation Issues Affecting The Review Process.................35
R ecommettdations..................................................40 Cone lu.sion..........................................................................................................42 Appendices.........................................................................................................43

CHILD FATALITY REVIEW ANNUAL REPORT EXECUTIVE SUMMARY
Accidents and diseases are the biggest killers of children in Georgia, according to
an analysis of 432 unexpected child fatalities that occurred between June 1990 and December
1991. One hundred forty of the deaths were classified as probably or definitely preventable.
Preventable accidents accounted for 74 of these fatalities. These and other findings by the Statewide Child Fatality Review Panel were derived
from an analysis of child death reports submitted to the panel by 62 county protocol
committees. The process for reviewing child fatalities is prescribed in legislation enacted by the Georgia General Assembly in 1990. The purpose of the county and statewide child
fatality review is to identify factors contributing to the unexpected or unexplained deaths of children, in particular factors related to child maltreatment, and to recommend action to prevent similar deaths. This report also contains recommendations to strengthen the review process.
Findings related to causes of death and characteristics of the children: 0 The top three causes of death were accidents (29.6%), diseases or natural cause
(23.1 %) and SIDS (21.3%).
0 More than half of the 81 children who died in accidents died in automobile collisions.
Child abuse is not a major cause of death. Eight fatalities involved child
maltreatment (not including deaths categorized as homicides). 0 Homicides constitute the fourth leading cause of death; most involve children using
firearms or knives. 0 Alcohol or drugs were involved in most of the accidental and homicide deaths.
0 Eighty-eight percent of the deaths occurred to children under age two.

0 Sixty-five percent of the fatalities were African Americans. 0 Males were at highest risk, accounting for 66% of the unexpected/unexplained fatalities and 45 of the 58 homicides. 0 A significant number of children died as a result of incidents involving firearms.
This is particularly true of deaths in the metropolitan Atlanta area. Such deaths were not
always accidental and included episodes related to "driveby" shootings and drug transactions. 0 Several children died as a result of drowning. These deaths often reflect seasonal
changes in counties with warmer climates, as well as the absence of adequate supervision.
Noting the high propartion of preventable accidental deaths due to motor vehicles
accidents, the panel also examined information regarding the use of seat belts and child safety seats. The panel concluded that proper use of a seat belt or child restraint may have prevented at least 47 of the deaths that occurred in auto accidents. Therefore, the panel recommends consideration of civil and criminal penalties for failure to properly use a seat belt or child restraint and that routine checks to encourage the use of seat belts and child
restraints be made by law enforcement officials.
The reviews by county protocol committees include a determination of agency
involvement with the child and his/her family. Agency involvement simply means whether
a community agency had contact with the family before or after the death. A more detailed analysis of this information will be done to assess any significance to preventing deaths.
Among the fatalities review activities and procedures marked for improvement are obtaining reports from counties that have an active review process but have not submitted reports; assuring that county protocol committees receive medical examiner/coroner reports in a timely manner and that deaths not adequately explained be subject to full investigation,
including an autopsy; requiring a complete death scene investigation; and clarifying the
issue of confidentiality to enable protocol committee members to more openly share information.

PREFACE
In 1990 legislation was signed into law that, for the first time in Georgia, required a systematic review of certain children's deaths. The purpose of the legislation and subsequent state statutes was to assure that unexpected and unexplained children's deaths would be subject to a multidisciplinary assessment and finding. In addition to examining the causes of deaths, the multidisciplinary review would also recommend measures for
preventing similar deaths.
The legislation was implemented during the latter part of 1990 and early 1991. Each county child abuse protocol committee was informed of its responsibility for reviewing children's deaths. The committees were given guidelines and other assistance and strongly encouraged to begin the reviews and to make recommendations for improving the process.
The legislation created a statewide panel which would receive the local committees' child death reviews. Its responsibilities include developing guidelines for reviews, analyzing local committees' reports, identifying issues related to prevention and providing an annual report to the governor. The panel has met five times since members were appointed in late
1990.
This document is the statewide panel's first annual report. It covers local reviews completed from June 1990 to December 1991. It begins with a history of child death reviews in Georgia and concludes with the state panel's recommendations.
The panel wishes to express its appreciation to the many organizations and individuals who have played important roles in implementing the review process thus far. Certainly the degree of success realized since 1990 is largely due to the commitment and determination of local protocol committees. Implementing the legislation has been a cooperative venture
into new responsibilities, involving many unknowns. -5-

The statewide panel believes that the fatality review process is having an impact. It challenges us to use the experiences and insights gained so far as guides to prevent more children from dying unnecessarily - which is the real goal of the legislation.
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HISTORY OF CHILD FATALITY REVIEW In 1990 the Georgia General Assembly passed legislation that created a child fatality
review requirement for the state. When Governor Joe Frank Harris signed the legislation in April, 1990 he was completing a process begun at least three years earlier.
For several years The Department of Human Resources' Division of Family and Children Services (DFCS) policy had required that deaths of children known to local departments of Family and Children Services be reported to staff in the State Social Service Section. The deaths were not routinely reviewed, although those which presented unusual circumstances were scrutinized by state level staff. In 1988, following the deaths of several children who were in active Social Services cases, the Division began to develop a child death review process. After examining procedures in other states, staff wrote review guidelines and field tested them.
The purpose of the review was to assess the circumstances of child maltreatment deaths and to make recommendations to prevent similar deaths. The review team was composed of local and state staff from various division within DHR in addition to DFCS. However, the statewide review process was not immediately implemented, due to the events described
below.
The press focuses public attention on child fatalities In 1989 the Atlanta Journal/Constitution published a series of articles on Georgia's
child welfare services. Among other issues, the articles examined the deaths of 52 children who were known to DFCS, the lack of a system for reviewing the causes of death and the unusually large number of children in Georgia whose deaths were attributed to SIDS. Although the great majority of the 52 children known to DFCS did not die from maltreatment, there was a perception that DFCS could have prevented their deaths. The articles ignited considerable public interest in improving state services for children.
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In response to the public support for fatality reviews and in light of the fact that DFCS had recently developed its own review system, DHR Commissioner James G. Ledbetter called for a review of each relevant division's policies and procedures regarding children's deaths, to determine whether a uniform policy could be created. An inter-divisional committee
met to review policies and procedures of the Divisions of Family and Children Services; Mental Health, Mental Retardation and Substance Abuse; and Youth Services.
Because each division's programs and target populations were unique, it was not possible
to develop one standard protocol. The Division of Mental Health, Mental Retardation and Substance Abuse had a review process in place, particularly for deaths occurring in residential
facilities. The Division of Youth Services also had procedures in place for its facilities.
As a result, the final recommendations focused primarily on the Divi.sion of Family and
Children Services.
Tile recommendations were presented to the Board of the Department of Human
Resources in October 1989. The Board adopted the recommendations but delayed their
implementation until the 1990 General Assembly could consider proposals being prepared
by its own legislative study group. In response to the publicity about children's deaths, the children's trust fund commission
requested and the governor appointed a task force of professionals to study tile issue of
unexplained deaths of children in Georgia. The Georgia Senate and the House of Representatives name legislative study committees to examine all issues related to child
abuse and the unexplained deaths. The Governor's Task Force on Child Fatality Review
The Task Force studied the 52 deaths which were a focal point of the newspaper series. Task Force members concluded that four of the 52 were tile result of maltreatment and
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that DFCS staff had been aware of the danger prior to the deaths. The Task Force recommended that "Georgia must develop a system to provide uniform death investigations by trained forensic pathologists to all areas of (the state)."
A second, equally important recommendation was that "Georgia must establish a statelevel multidisciplinary death review team for thorough investigation of children's deaths." The Task Force report cited examples of the need for cooperation among those responsible for protecting children and noted that many other states had taken a team approach. It recommended at least three purposes for the multidisciplinary team:
1) To thoroughly review each death, based on selected criteria 2) To identify flaws in the methods agencies use for dealing with children 3) To assure accountability for anyone responsible for a child's death because
of maltreatment. In addition, the Task Force provided recommendations pertaining to confidentiality, tracking and reporting of cases, staff training and resources. The General Assembly took actions paralleling those the Governor. Both the Senate and the House appointed legislative study committees, which held hearings and developed a series of proposals. Among these proposals was a bill to amend the existing statute for county child abuse protocol committees to assign the committees responsibility for fatality reviews. This bill was passed in the 1990 legislative session. In addition, amendments were made in the statutes related to death investigations, supporting the review and inquiry into certain deaths of children. These amendments reflected the Task Force's recommendation to provide uniform investigations by forensic pathologists and to require autopsies of infants prior to assigning SIDS as the cause of death.
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THE CHILD FATALITY REVIEW PROCESS
The process for reviewing a child fatality is prescribed by the legislation requiring the review. It is a fairly uncomplicated procedure, resulting in a flow of information from the local communities to the state level.
The accompanying flow chart (Appendix A) shows the sequence of events. When the unexpected or unexplained death of a child is investigated and reported to the Georgia Bureau of Investigation, a copy of the report is sent to the local child abuse protocol committee in the child's county of residence. [O.C.G.A. 19-1-3(a)]
When the chairman of the committee receives a report, other members are notified and convened within 10 days. The committee meets to review the death report and begin its own investigation. This process includes review of any relevant documents from agencies which had contact with the child. If necessary, the committee can request the superior court judge to subpoena material and/or witnesses. Information provided to the committees is considered confidential.
The committee's investigation is to be completed within 20 work days after receipt of the death report. The committee must send a report of its review and conclusions to the statewide panel within 15 days after completing the investigation. The total process prescribed by the statute would take a maximum of 45 days.
The committee's report should include information about 1) the circumstances and factors contributing to the death; 2) the extent and type of agency involvement prior to and at the time of the death; 3) a determination of whether the death was preventable; and 4) recommendations, either regarding the specific situation or of a general nature.
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If the review concludes that the death was due to any of eight reasons specified in the statute, a copy of the report is also forwarded to the district attorney. Among the reasons are SIDS without an autopsy; deaths from accidents or medical causes which could
have been prevented; suicide and child abuse.
The county protocol committees' reports are sent to the Statewide Child Fatality Review Panel which was created in the legislation. The panel is composed of seven members,
including the chairman of the board of Human Resources, the director of the Division of Family and Children Services, the director of the Georgia Bureau of Investigation, and four
members appointed by the Governor: a juvenile court judge, a district attorney, a citizen
representative, and a forensic pathologist.
One of the panel's main responsibilities was to develop and issue guidelines for the local committees' reviews of children's deaths. Guidelines were produced and submitted to protocol committee chairpersons, medical examiners, coroners, county directors of Family and Children Services and chief judges of Superior Court circuits.
The panel is required to meet yearly or as often as needed to review all reports submitted. After reviewing each year's activity, the panel is to submit an annual report to the Governor. In general, the report is to indicate how many deaths occurred and under what circumstances, provide recommendations for preventing deaths not from natural causes
and address other issues such as prevention, intervention, and policy changes.
The panel itself is authorized to conduct reviews of deaths, if the chair believes they
are warranted and a local committee requests the review.
Meetings of the state panel are open to the public, although they may be closed if confidential information is discussed. The protocol committee reviews are closed to the
public. Reports by the panel and the protocol committees are public documents, although
information identifying individuals involved in the cases will be expunged.
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DATA ANALYSIS
Data for the fatality review annual report have been taken from the reparts submitted by local protocol committees to the statewide panel. The data in this report cover a time period from June, 1990 through December, 1991. In order to do the narrative and data analysis in 1992 for the first report to the Govemor, no reviews after December, 1991 are
included. Reparts received after this date will be included in annual reports from the statewide panel each year.
The number of reparts analyzed is 432, from 62 counties. It should be noted that more reports were received after December, 1991 and -additional counties submitted reparts. If the later reparts are counted, there are approximately 500 reparts received by the end of April, 1992. (See Appendix B for copy of fatality review report form.) Findings and Results
Sixty two (62) of Georgia's 159 counties submitted child fatality reviews to the
Statewide Child Fatality Review Panel for the period June 1990 through December 1991
(Table 1). Thirty seven (3 7) of the sixty two counties submitted two or less reviews and twenty six counties covered time periods of less than two months. It should be noted that
several counties within Georgia's standard metropolitan statistical areas, i.e. urban areas,
are underreported or missing from this analysis. Douglas County from the Atlanta MSA and Muscogee County from the Columbus MSA are examples. These are not the only counties
which are missing or underreported during the time period covered. (Tables 2 and 3) Cause of Deaths
The review process requires the county protocol committees to classify the child
fatalities into 9 general categories (Medical, Disease or Natural, SIDS, Homicide, Child Abuse/Neglect-suspect, Child Abuse/Neglect-confirmed, Suicide, Accident, Undetermined).
The child abuse categories were combined in the analysis. The top three categories of cause
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of death reported on the reviews were accident (29.6%), disease 6r natural (23.1 %), and SIDS (21.3%) (Table 4). Infant deaths (under age 1) accounted for 76.8 (199) of the child fatalities. The top three categories of death for infants were SIDS, disease or natural, and accident. Children over the age of 1 died from accidents, homicide, and disease or natural causes in rank order (Table 4). SIDS, which affects infants only, was reported as the cause of death to one 3 year old and one 17 year old.
Gender and Race Males accounted for 66.4 % of the unexpected/unexplained fatalities (Table 5 Gender
of Deceased). Males accounted for 45 of the 58 homicides. Only in the category of medical did females outnumber males.
Approximately fifty nine percent (59.3%) of the unexpected/unexplained fatalities
were to African-American children (Table 6 Race of Deceased). Race and gender are compared by category of death in Table 7.
Autopsies and Death Certificates
Autopsy reports were submitted with 304 (70.4%) of the reviews. Of note is that autopsy reports were submitted for 83. 7% (77) of the 92 SIDS fatalities. (Table 8)
Death certificates were submitted for only 113 (26.2%) of the 432 fatalities. All but
one of the reviews for fatalities of an undetermined cause were submitted without a death
certificate. (Table 9) Agency Involvement
Agencies were involved with the deceased prior to death in 69. 7% (301) of the reported cases. For 77 (17.8%) of the cases the agency involvement was not reported. Agency involvement means that an agency (usually public) had a record of contact with the child
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and/or the family. The agency's involvement may have occurred before the death, may
have been active at the time of death or happened after the death. It is important to note
that the element of agency involvement is not assessed with respect to prevention of deaths.
This is a factor to be analyzed further in the data assessment process. (Table 10)
Preventability One hundred forty (32.4%) of the reported unexpected/unexplained fatalities were
classified as definitely or probably preventable by the review process. Seventy five of the 432 fatalities or approximately 17.4% of the fatalities were definitely preventable according to the review process. Preventable accidents accounted for 51.4% of the preventable
fatalities and 17% of the total unexpected/unexplained fatalities reported. For 25 (5.8%)
of the fatalities preventability was unable to be determined. Individual evaluation of preventability by agency review cannot be analyzed at this time. (Table 11) Chi'ld Fatality Review - Trends for the 1990-1992 Period
Statewide child death reports submitted for the period June 1990 through April 1992
are reflected in Table 12. The totals are different from previous tables and reflect that
total period. Table 12 is intended to show trends of reporting; further analysis will be forthcoming. Methodology
The data entry process for the child fatality reviews has generated five interrelated
datasets for analysis. The primary dataset is the basic information on the county committee
child fatality review form. Related datasets contain socioeconomic and case identifier
information, information on significant relationships of the deceased, agency involvements
with the deceased, and information gleaned from death certificates attached to the reviews. Data from the reviews were entered by professional volunteers and/or part-time staff.
They entered as much information as possible from the materials submitted to the Office
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of Epidemiology, Division of Public Health. This process resulted in at least 12 duplicate cases at varying levels of completeness. The information in these cases has been combined
and duplications eliminated.
No response (missing values) or inaccurately coded information is a constant problem
with all data collection and analysis. Only a quick review of the data has been done to
correct inaccurately entered data. Of the variables analyzed to date, missing values are occurring at less than 5% of the records. The determination of preventability by the review
process has 48 missing responses (11 %). Agency involvement with the deceased, significant
relationships of the deceased, and whether a death certificate was attached to the review have no response in a small percentage of the reports. The categories of death, race of the deceased, and whether an autopsy report was attached to the review were also missing,
in a small percentage. For this initial analysis the missing values (no responses) were added
to the no, unknown and undetermined responses. Remaining Data Analysis Issues
These results are a from an initial run of some very basic variables in the primary dataset. More specific analysis could be done using the additional information in the related datasets. For additional analysis a more thorough cleaning of the datasets needs to take place, especially focusing on the variables that allow the datasets to be related to each other for analysis.
Results from the child fatality review process will need to be compared directly witll additional in-state data sources, for example death certificate files and with results from other states. The broad categories of cause of death will not facilitate this process. Identification of the causes according to the International Classification of Diseases codes would allow these comparisons to take place.
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Table 1
COUNTY CHILD DEATH REPORTS, ATTACHED DATA, AND DATES OF FIRST AND LAST REPORTS
Rank Ordered by dale of first death report, Georgia, June 1990-December 1991

Reporting County

Deaths Reported

Autopsy Deaths Report Reviewed Attached

Death Certificate Attached

Dale of Death Nol Reported

Date of

Deaths Reported

First

Last

Interval (Months)

1 Chattooga

1

1

0

0

1

2 Hall

9

9

0

0

9

3 Terrell

1

0

0

0

1

4 DeKalb

88

88

78

4

Jun 90 Nov 91

18

5 Catoosa

8

8

2

8

Jul90 Apr 91

10

6 Clayton

20

18

18

1

Jul 90 Oct 91

15

7 Fannin

I
'-

8 Fulton

0)

I

9 Gwinnett

2

2

1

0

Jul 90 Dec 91

18

106

106

100

7

3 Jul 90 Dec 91

18

32

31

16

4

2 Jul 90 Dec 91

18

10 Henry

6

6

4

2

Jul 90 Oct 91

16

11 Macon

2

2

2

2

Jul 90 Mar91

9

12 Tilt

6

6

2

6

Jul90 Aug 91

14

13 Camden

1

1

1

0

Aug 90 Aug90

1

14 Lowndes

18

18

9

2

Aug 90 Aug 91

13

15 Pickens

1

1

0

0

Aug 90 Aug90

1

16 Colquitt

1

1

1

0

Sep 90 Sep 90

1

17 Dougherty

8

8

7

1

Sep90 Jun 91

10

18 Habersham

2

2

2

2

Sep90 Oct90

2

19 Libert}'.

10

10

10

10

Sep 90 See 91

13

20 Bryan

1

1

1

1

Oct 90 Oct 90

1

21 Chatham

13

13

3

8

Oct 90 Apr91

7

22 Whitfield

10

10

8

5

1 Oct 90 May 91

8

23 Worth

4

4

1

4

Ocl90 Apr91

7

24 Ben Hill

1

1

1

1

Nov90 Nov90

1

25 Clat1<e

2

2

1

2

Nov90 Sep 91

11

26 Glynn

6

6

2

6

Nov 90 Nov 91

13

27 Houston

8

8

0

0

Nov90 Nov 91

13

28 Oglethorpe

1

1

1

0

Nov90 Nov 90

1

29 Dooly

1

1

1

1

Dec90 Dec 90

1

30 Evans

1

1

1

1

Dec 90 Dec 90

1

31 Cobb

12

12

0

0

4 Jan 91 Aug 91

8

32 County Unknown

4

0

0

0

3 Jan 91 Jan 91

1

Reporting County

Dealhs Reported

Aulopsy Deaths Report Reviewed Attached

Dealh Certificate Atlached

Date of Death Nol Reported

Daleo!

Deaths Reported

First

Last

Interval (Months)

33 Crisp

34 Madison

35 Baker

36 Clinch

37 Echols

38 Forsyth

39 Spalding

40 Walker

41 Tatlnall

42 Ellingham

43 Franklin

44 Johnson

..I...

45 Long

~
I

46 Grady

47 Troup

48 Wilkes

49 Brooks

50 Morgan

51 Irwin

52 Lincoln

53 Mitchell

54 Early

55 Harris

56 McIntosh

57 Greene

58 Thomas

59 Bibb

60 Elbert

61 Union

62 Haralson

2

2

2

1

1

1

3

3

3

1

1

0

1

1

0

7

7

2

5

5

0

2

2

2

2

2

1

2

2

1

2

2

1

1

1

0

3

2

2

2

2

0

2

1

1

2

2

2

1

1

1

3

3

2

2

2

2

1

1

1

1

1

1

1

1

0

1

0

0

1

1

1

2

2

2

3

3

1

21

0

0

1

1

1

1

1

1

1

1

0

1

Jan 91 Oct 91

10

1

Jan 91 Jan 91

1

2

Feb 91 Dec 91

11

0

Feb 91 Feb 91

1

1

Feb 91 Feb 91

1

7

Feb 91 Oct 91

9

0

Feb 91 May 91

4

0

Feb 91 Mar 91

2

2

Mar91 J~l91

5

0

Apr 91 Jun 91

3

2

Apr 91 Jul 91

4

0

Apr 91 Apr 91

1

2

Apr 91 Jun 91

3

1

May 91 Jul 91

3

0

May 91 Nov 91

1

1

May 91 Ocl 91

6

1

Jun 91 Jun 91

1

2

Jun 91 Dec 91

7

2

Jul 91 Jul 91

1

0

Jul91 Jul 91

1

1

Jul91 Jul91

1

1

Aug 91 Aug 91

1

0

Aug 91 Aug 91

1

1

Aug 91 Aug 91

1

2

Sep 91 Sep 91

1

3

See 91 Ocl 91

2

0

20 Ocl 91 Oct 91

1

1

Oct 91 Oct 91

1

1

Nov 91 Nov91

1

0

Dec 91 Dec 91

1

Total Percent

464

432

304

100.0% 93.1% 65.5%

113 24.4%

44 9.5%

Source: County Child Fatality Review Committees, reports received prior lo April 1, 1992. 97 Counties not reporting.

Table 2
METROPOLITAN STATISTICAL AREAS (MSA) CHILD DEATH REPORTS, ATTACHED DATA, AND DATES OF FIRST AND LAST REPORTS
(Georgia, June 1990 - December 1991)

MSA

Number of Counties Counties Reporting

Deaths Reported

Autopsy Deaths Report Reviewed Attached

Death Certificate Attached

Date of Death Not Reported

Date of

Deaths Reported

First

Last

Interval (Months)

Albany

2

1

8

8

7

1

0 Sep 90 Jun 91

10

Athens

4

2

3

3

2

3

0 Nov 90 Sep 91

11

Atlanta

18

8

276

273

218

25

9 Jun 90 Dec 91

19

Augusta

3

0

0

0

0

0

0

.!.. Columbus

2

0

~ Chattanooga

3

2

0

0

0

0

0

10

10

4

8

0 Jul90 Apr 91

10

Macon

4

2

29

7

0

0

20 Nov90 Nov 91

13

Savannah

2

2

15

15

4

8

0 Oct90 Jun 91

9

MSA Total

36

15

326

301

231

37

29 Jun 90 Dec 91

19

Percent

100.0%

41.7%

100.0%

92.3%

70.9%

11.3%

8.9%

Non-MSA Total

123

47

138

131

73

76

15 Jun 90 Dec 91

19

Percent

100.0%

38.2%

100.0%

94.9%

52.9%

55.1%

10.9%

State Total

159

62

464

432

304

113

44 Jun 90 Dec 91

19

Percent

100.0%

39.0%

100.0%

93.1%

65.5%

24.4%

9.5%

Source: County Child Fatality Review Committees, reports received prior to April 1, 1992.

Table 3
METROPOLITAN STATISTICAL AREAS (MSA) CHILD DEATH REPORTS, BY CATEGORY OF DEATH AMONG CHILDREN UNDER AGE 18
(Georgia, June 1990 - December 1991)

Category of Death

MSA

Accident

Disease or Natural

SIDS

Homicide Undetermined Suicide

Medical

Child Abuse

Albany

2

Athens

1

Atlanta

70

Augusta

0

I Columbus

0

cpi,....
Chattanooga

6

Macon

4

Savannah

2

4

2

0

1

1

0

60

60

41

0

0

0

0

0

0

2

2

0

1

1

0

10

0

0

0

0

0

0

0

0

0

0

9

12

9

4

0

0

0

0

0

0

0

0

0

0

0

0

1

0

0

1

1

1

0

1

MSA Total Percent

93 72.7%

78 78.0%

66 71.7%

41 70.7%

11 61.1%

13 81.3%

9 75.0%

6 75.0%

Non-MSA Total

35

Percent

27.3%

22 22.0%

26 28.3%

17 29.3%

7 38.9%

3 18.8%

3 25.0%

2 25.0%

State Total Percent

128 100.0%

100 100.0%

92 100.0%

58 100.0%

18 100.0%

16 100.0%

12 100.0%

8 100.0%

Source: County Child Fatality Review Committees, reports received prior to April 1, 1992.

Total Deaths

Percent

8

2.5%

3

0.9%

273

86.1%

0

0.0%

0

0.0%

10

3.2%

8

2.5%

15

4.7%

317 73.4%

100.0%

115 26.6%

432 100.0%

Table 4
CATEGORY OF UNEXPECTED DEATHS AMONG CHILDREN UNDER AGE 18
(Georgia, June 1990 - December 1991)

Age at Death (Years) Accident

Disease or Natural

SIDS

Homicide

Undetermined Suicide Medical

0

21

56

90

8

12

0

7

1

6

15

0

4

1

0

3

2

7

3

0

4

1

0

1

3

9

5

1

2

0

0

0

4

6

1

0

1

2

0

0

5

3

2

0

3

0

0

0

6

4

1

0

0

0

0

0

7

1

1

0

0

1

0

1

8

2

1

0

0

0

0

0

9

6

1

0

0

0

0

0

10

6

1

0

1

0

0

0

11

4

1

0

2

0

0

0

12

3

3

0

2

0

1

0

13

3

0

0

3

0

0

0

14

8

2

0

6

1

6

0

15

9

0

0

2

0

1

0

16

15

4

0

9

0

4

0

17

15

3

1

11

0

4

0

rotal =>ercent

128 29.6%

100 23.1%

92 21.3%

58 13.4%

18 4.2%

16 3.7%

12 2.8%

3ource: County Child Fatality Review Committees, reports received prior to April 1, 1992.

Child Abuse

Total Deaths Percent

5

199 46.1%

0

29 6.7%

0

16 3.7%

3

20 4.6%

0

10 2.3%

0

8 1.9%

0

5 1.2%

0

4 0.9%

0

3 0.7%

0

7 1.6%

0

8 1.9%

0

7 1.6%

0

9 2.1%

0

6 1.4%

0

23 5.3%

0

12 2.8%

0

32 7.4%

0

34 7.9%

8

432

1.9%

Table 5
GENDER BY CATEGORY OF UNEXPECTED DEATHS AMONG CHILDREN UNDER AGE 18
(Georgia, June 1990 - December 1991)

Category of Death

Gender

Accident

Disease or Natural

SIDS Homicide Undetermined Suicide

Male

82

69

58

45

10

12

Female

43

29

32

12

5

4

Not Reported

3

2

2

1

3

0

I
,t-_..::

I Totals

128

100

92

58

18

16

Source: County Child Fatality Review Committees, reports received prior to April 1, 1992

Medical
4 8 0
12

Child Abuse
7 1 0
8

Total Deaths Percent
287 66.4% 134 31.0%
11 2.5%
432

Table 6
RACE BY CATEGORY OF UNEXPECTED DEATHS AMONG CHILDREN UNDER AGE 18
(Georgia, June 1990 - December 1991)

Category of Death

Race

Accident

Disease or Natural

SIDS Homicide Undetermined

Suicide

White

66

33

30

8

7

5

Black

56

62

58

48

9

10

Asian

1

1

1

0

0

1

~ Hispanic

1

2

2

1

0

0

1 Unknown

4

2

1

1

2

0

Total

128,

100

92

58

18

16

Source: County Child Fatality Review Committees, reports received prior to April 1, 1992.

Medical
4 8 0 0 0
12

Child Abuse
2 5 0 0 1
8

Total Deaths Percent

155 35.9%

256 59.3%

4

0.9%

6

1.4%

11

2.5%

432

Table 7
RACE AND GENDER BY CATEGORY OF UNEXPECTED DEATHS AMONG CHILDREN UNDER AGE 18
(Georgia, June 1990 - December 1991)

Category of Death

Race

Gender

Accident

Disease or Natural

SIDS Homicide Undetermined

While

Male

48

24

19

6

4

(N=155) Female

18

9

11

2

2

Unreported

0

0

0

0

1

Black

Male

32

43

38

38

6

I (N=256) Female

24

19

20

10

3

ts.,

c:.,

Unreported

0

0

0

0

0

I

Asian

Male

1

0

0

0

0

(N=4)

Female

0

1

1

0

0

Unre12orted

0

0

0

0

0

Hispanic Male

1

2

1

1

0

(N=6)

Female

0

0

0

0

0

Unreported

0

0

1

0

0

Unknown Male

0

0

0

0

0

(N=11) Female

1

0

0

0

0

Unreported

3

2

1

1

2

Total

128

100

92

58

18

Source: County Child Fatality Review Committees, reports received prior to April 1, 1992.

Suicide
4 1 0 8 2 0 0 1 0 0 0 0 0 0 0
16

Medical
2 2 0 2 6 0 0 0 0 0 0 0 0 0 0
12

Child Abuse
2 0 0 4 1 0 0 0 0 0 0 0 1 0 0
8

Total Deaths Percent

109 70.3%

45 29.0%

1 0.6%

171 66.8%

85 33.2%

0

0.0%

1 25.0%

3 75.0%

0

0.0%

5 83.3%

0

0.0%

1 16.7%

1

9.1%

1 9.1%

9 81.8%

432

Table 8
AUTOPSY REPORT SUBMITTED WITH REVIEW BY CATEGORY OF UNEXPECTED DEATHS AMONG CHILDREN UNDER AGE 18
(Georgia, June 1990 - December 1991)

Category of Death

Submitted

Accident

Disease or Natural

SIDS Homicide Undetermined

Suicide Medical

Yes
, No
t\., .::,. I
Total

66

71

77

51

62

29

15

7

128

100

92

58

12

13

10

6

3

2

18

16

12

Source: County Child Fatality Review Committees, reports receoved prior to April 1, 1992.

Child Abuse
4 4
8

Total Deaths Percent
304 70.4% 128 29.6%
432

Table 9
DEATH CERTIFICATE SUBMITTED WITH REVIEW BY CATEGORY OF UNEXPECTED DEATHS AMONG CHILDREN UNDER AGE 18
(Georgia, June 1990 - December 1991)

Category of Death

Submitted

Accident

Disease or Natural

SIDS Homicide Undetermined

Suicide

Yes
No
I
et"n'
I Total

38

27

26

13

90

73

66

45

128

100

92

58

1

3

17

13

18

16

Source: County Child Fatality Review Committees, reports received prior to April 1, 1992.

Medical
2 10
12

Child Abuse
3 5
8

Total Deaths Percent
113 26.2% 319 73.8%
432

Table 10
AGENCY INVOLVEMENT INDICATED ON REVIEW BY CATEGORY OF UNEXPECTED DEATHS AMONG CHILDREN UNDER AGE 18
(Georgia, June 1990 - December 1991)

Category of Death

Agency Involvement

Accident

Disease or Natural

SIDS Homicide Undetermined Suicide

Yes

79

No

6

~ Unknown

21

~ Not Reported

22

69

68

48

3

2

0

7

7

2

21

15

8

10

11

0

0

3

1

5

4

Total

128

100

92

58

18

16

Source: County Child Fatality Review Committees, reports received prior to April 1, 1992.

Medical
10 2 0 0
12

Child Abuse
6 0 0 2
8

Total Deaths Percent

301 69.7%

13

3.0%

41

9.5%

77 17.8%

432

Table 11
ASSESSMENT OF PREVENTABILITY THROUGH THE REVIEW PROCESS BY CATEGORY OF UNEXPECTED DEATHS AMONG CHILDREN UNDER AGE 18
(Georgia, June 1990 - December 1991)

Category of Death

Preventable

Accident

Disease or Natural

SIDS Homicide

Undetermined Suicide

Definitely

41

0

1

25

~ Probably

33

13

5

5

~ Probably Not

12

25

23

8

Definitely Not

21

49

50

9

Undetermined

5

7

3

4

Not Reported

16

6

10

7

2

0

3

4

1

9

1

1

6

0

5

2

Totals

128

100

92

58

18

16

Source: County Child Fatality Review Committees, reports received prior to April 1, 1992.

Medical
2 1 3 6 0 0
12

Child Abuse
4 1 1 0 0 2
8

Total Deaths Percent

75 17.4%

65 15.0%

82 19.0%

137 31.7%

25

5.8%

48 11.1%

432

r.:.6Ll 12 CHILD Ol;.TH RfPORTS ATTACHED OAT;.. ANO OATES OF FIR5T ANO LAST J.EPORTS

RJn-. Ort1er~C l>v '1,"\IC 01 11,sr <J~ilfr, ,eport, Geo,o June 1990-eo,uav 199::

OelhS County Neme F<eoor1ed

Chanooga

1

2 Hall

9

J Terrell

4 DeKalb

88

5 Catoosa

8

6 ClaV1on

20

7 Fannon

2

8 Fullen

109

9 Gwonnrn

34

10 Henry

6

11 Macon

2

12 Tift

6

1 J Camden

14 Lownoes

18

1S Pod.ens

16 ColQuoll

1 7 Doughet1y

8

18 Habersham

2

19 Liberty

10

::?0 (3ryan

1

::?1 Chatham

13

::?2 Wh,1field

10

23 Wot1h

4

24 Ben Holl

1

::?S Clarke

2

26 Glynn

7

27 Houston

8

28 Oglethorpe

29 Dooly

JO Evnns

1

J 1 Cobb

12

32 Cri::o

2

33 M.ido::on

30: Countv Unic.now

4

JS B,~k.cr

J

36 Clinch

1

J 7 Echols

1

38 For::~~h

7

39 Spalding

6

40 \Velk.er

2

.:1 T,innall ..:2 Etfi,it;ham

.2
~

.:3 Frank:l1n

3

.a...:. Johnson

1

.:5 Long

J

46 Graoy

::

.:.7 Troup

2

.:a Wilkes

::

.:9 Brook::

1

50 Morgan

3

51 Irwin

2

52 Llncoln

2

SJ Mitchell

54 Eer1y

55 Hnrri::
--~~

1 2

57 Greene

2

58 Thomes

J

59 S..bb

21

60 Elbert

1

61 Union

1

62 Haralson

63 Appling

64 FloVCI

Oee1hs
Revtewed

Aulopsy
Repor, A11eched

Oee1h
Cer1ofoce1e
Anecheel

Oe of

Oee1h De1e Dee1hs Reported

No1 Repo,1eel First

Last

ln1erval
(Monlhsl

1

0

0

9

0

0

0

0

0

88

78

4

8

2

8

18

18

1

2

1

0

109

103

7

33

18

6

6

4

2

2

2

2

6

2

6

t

1

0

18

9

2

0 ,

0 0

8

7

1

2

2

2

10

10

10

1

1

1

13

3

8

10

8

5

4

4

1

1

2

1

2

7

3

7

7

0

0

0

1

1

1

1

12

0

0

2

2

1

1

1

0

0

0

3

J

2

0

0

1

0

1

7

2

7

6

0

0

2

2

0

2

2

2

0

J

2

3

1 2

.0
~

0 2

2

0

1

0

:

2

1

1

J

2

2

:z.

2

2

2

, 1

0

1

0

1

0

0

0

:z.

2

:z.

2

2

3

3

0

0

0

1

0

0

1

0

1 9

Jun 90 Nov 91

18

Jul 90 Apr 91

10

Jul 90 Oct 91

15

Jul90 Oec 91

18

J Jul 90 Jan 92

19

2 Jul 90 Feb 92

19

Jul 90 Oct 91

16

Jul 90 Mar 91

9

Jul 90 Aug 91

14

Aug 90 Aug 90

1

Aug 90 Aug 91

13

Aug 90 Aug 90

Sep 90 Sep 90

Sep 90 Jun 91

10

Sep 90 Oct 90

2

Sep 90 Sep 91

13

Oct 90 Oc190

1

Oct 90 Apr 91

7

Oc190 May 91

8

Oct 90 Apr 91

7

Nov 90 Nov 90

Nov 90 Sep 91

11

Nov 90 Jan 92

15

Nov 90 Nov 91

1 J

Nov 90 Nov 90

Dec 90 Dec 90

Dec 90 Dec 90

1

4

Jan 91 Aug 91

8

Jan 91 Oct 91

10

Jan 91 Jan 91

3 Jan 91 J,1n 91

Feb 91 Dec 91

11

Feb 91 ;:eo 91

1

Feb 91 Feb 91

1

Feb 91 Oct 91

9

Feb 91 Feb 92

13

Feb 91 Mar 91

2

Mer 91 Jul 91

5

Apr 91 Jun 91

3

Apr 91 Feb 92

11

Apr 91 Apr 91

I

Apr 91 Jun 91

3

May 91 Jul 91

J

May 91 Nov 91

1

May 91 Oct 91

6

Jun 91 Jun 91

1

Jun 91 Dec 91

7

Jul 91 Jul 91

1

Jul 91 Jan 92

7

Jul 91 Jul 91

Aug 91 Aug 91

Aug 91 Aug 91

1

Aug 91 Feb 92

7

Sep 91 Sep 91

1

Seo 91 Oct 91

2

20 0.;1 91 Oct 91

Oct 91 Oct 91

Nov 91 Nov 91

Dec 91 Oec 91

Jan 92 Jan 92

Jen 92 Jan 92

Totals Percent::

476 100.0%

443 93.1%

313 65.8%

119 25.0%

44 9.2%

Rov.ew of nll repotls 01 OHR on Aprtl

1992. 95 countu,s have not rt,ported.

-:!R-

Reported Unexpected/Unexplained Child Fatalities* Category of Cause of Death
Georgia, June 1990 - December 1991

SIDS 21.3%

Medical 2.8%.

Suicide 3.7%
I ~
to
I , '
Disease/Natural 29.6%

Homicide 13.4%

Child Abuse

jr _., 1: jj!.i~i" i;p~;i,.,1

i;ri:: r~J 1:!tflf.P:t,Hsi
iK.J:',1; 1!p~i-:,

,~-;1q1:Jtl:~'.

11!1mI!rir1:1

-rr J-+ ,- '. ,.
.~ >

': .

!''
H

::1 11lJd11'_Jf''_

1

Accident

23.1 %

1.9%

Undetermined 4.2%

Total reported unexpected/unexplained child fatalities= 432 Source: County Child Fatality Review Committees, reports received prior to April 1, 1992.

Reported Unexpected/Unexplained Child Fatalities*

By Category of Death and By Age

Georgia, June 1990 - December 1991
140
D 1 Year and Over
120
(ii Under 1 Year
100

Cf)

t.I :
C

:=Q-:): 80 ,_

I

ctl

+-'

ctl LL

60

40

20

0 Accident Disease/Natural SIDS Homicide Undetermined Suicide
Category of Death
Total reported unexpected/unexplained child fatalities = 432 Source: County Child Fata lily Review Cornrnillees, reports received prior to April 1, 1992.

Medical Child Abuse

ADDITIONAL INFORMATION FROM FATALITY REPORTS
In addition to the above data regarding the incidence and circumstances of deaths, county protocol committees' reports also contained recommendations about preventing deaths. The recommendations from reviews primarily concem accidental deaths, though there are a number of proposals related to other causes of deaths. The following information summarizes recommendations from committees and categorizes them generally according to the circumstances of death. The strategies have been thoughtful and innovative, and if implemented, could profoundly affect the reduction of fatalities.
Drowning
Supervision of pools (private and community), swimming instruction to children, lifeguards trained in CPR, enforced rules and regulations at community pools, child proof pools, i.e., fences around pools (residential), better locks on swimming pools, water safety instruction, limiting pool capacity, public notification of swimming pool rules.
Motor Vehicle (Car and Motorcycle) Accidents - Passenger and Driver
Reduction of speed, driver education to increase experience, seat belts, proper child restraint seats, community car seat safety and seat load programs, tinted face plate (motorcycle helmet), post-partum classes on infant car seat safety, regulations preventing infants from leaving hospitals unless in car seats, price control of child restraints, fines and stricter enforcement of child restraint regulations.
SIDS
Monitoring of siblings, identify SIDS risk factors, accessible prenatal care, in-patient drug treatment programs for pregnant substance abusers, prenatal smoking cessation programs.
-31-

Stillbirths Accessible prenatal care, delivery at hospital, prevent substance abuse, in-patient
drug treatment programs for pregnant substance abusers. Homicide or Suicide Involving Guns
Strict gun control and enforcement, firearm seclusion, parental responsibility for gun safety, firearm maintenance, drug and alcohol counseling, in-patient and out-patient drug and alcohol treatment programs, crisis counseling, school intervention, family counseling. Homicide and Suicide
Counseling at school, child protection referrals and follow up with schools, family,
and courts, expanded DFCS services to high risk families, follow-up when child depressed,
drug and alcohol counseling and treatment, family counseling. Other Observations
In addition to the analysis of the data and the recommendations concerning prevention,
there are several other general observations from the reviews. These include the following: (1) Age of Chfldren: The greatest number of children is in the one year
and under group. This group is dependent on primary caretakers, often
in situations of high risk health at birth. These conditions may be due to mothers who are abusers of various substances (including tobacco),
thereby creating risk factors related to a high probability of SIDS, respiratory problems, etc. These children often are not exposed to
the community; thereby identification of appropriate services is not as probable. The number of children between the ages of 3-13 in the reviews is not remarkable. It is suggested that the reasons for such are that, at these ages, children are more mobile and verbal, as well as in contact with
-32-

institutions other than their families. Though this age range is lower in number of deaths, further analysis of agency involvement or contact
could identify changes to improve safety and well-being of children 3-13 years old. (2) Chi'ld Maltreatment Deaths: Strongly associated with the development
of a child fatality review was the wide perception that many children were dying because of parental maltreatment. As the protocol
committee reports reviewed, it became apparent that child
maltreatment is not a leading cause of children's deaths excluding deaths
for which homicide by caretaker is indicated as the cause. The percentage of deaths attributed to child abuse or neglect by the multidiscipline reviews is less than 2% of total reported causes of deaths.
Any child's death from parental negligence or abuse is tragic, undesired and probably preventable - in the broadest sense. However, it is clear that the review process has provided a much needed, and more accurate,
perspective to the issues of unexplained or unexpected deaths in general and the deaths due to child maltreatment specifically. (3) General Conclusions: Several general conclusions can be developed with regard to the child fatality review implementation and process.
These conclusions derive from results or progress attributed to a
systematic examination of unexplained or unexpected deaths. They include:
0 a knowledge base or reference for why and how Georgia's children are dying and some indicators to direct future efforts;
-33-

0 an increased degree of inter-agency involvement, with more problem solving which is focused on prevention and/or reducing unnecessary children's death;
0 linkage and accountability between families of dead children, county and state level agencies and the executive/legislative branches of government;
0 a network within the state, linked to a national network, concentrating on the prevention of children's deaths.
-34-

IMPLEMENTATION ISSUES AFFECTING THE REVIEW PROCESS
The cooperative effort of the counties and their individual review committees is meritorious. It is evident that some counties have gone to great lengths to implement the process and submit information. In these instances, the high quality of the data enhances the accuracy of analysis.
Also contributing to the accuracy of the review process is the high autopsy rate. The state's overall autopsy rate is 10% - 15%. The autopsy rate for the deaths investigated during the review process is 70.4%. The high rate of autopsies will increase knowledge about the causes of death and opportunities to identify prevention strategies.
The process, however, is not perfect. Several problems limit the quality of the process and the applicability of the data. Following is a summary of the problems, along with recommendations for improvement:
1. Insufficient rwmber of counties sent in reports. While county participation has improved, reviews from only 62 out
of the state's 159 counties have been analyzed. What accounts for the small number of counties submitting reviews? A study by the Center for Urban Policy Research at Georgia State University indicates that county departments of Family and Children Services and district attorneys were very familiar with the review process. Other groups were not as well informed. (See Appendix C for information from the CSU survey.) Incomplete information regarding the fatalities affects quality control as well as the ability to identity risk factors.
-35-

Failure to send reports may be due to: 0 no deaths appropriate for review; 0 some coroner/medical examiner may lack understanding regarding
legal requirements; 0 an arbitrary decision to not send reports to protocol committee; 0 some county protocol committees may not be active. Recommendation: Contact counties which have not sent reports to determine why. Consider review of death certificates for children to identify additional cases.
2. Reports were slow to come to the local committee. The statute did not specify a time period within which the
coroner/medical examiner should submit the report to the protocol committee. Lengthy investigations cause some reports to reach the committees long after the time of deaths. Though no instances are noted, untimely reports could put other children in the home at risk. Recommendation: Review and consider alternatives to notify local committee or officials so that an assessment of risk to other children may be determined.
3. Auto~ reports were delayed.
Some autopsy reports were not available to the protocol committees within the specified time frames. No intentional delays were identified. Rather, the delays in autopsy reports often are due to delays in receiving toxicology reports. Recommendation: Support allocation of additional resources to improve death examination system.
-36-

4. The committees' relationship to witnesses is wtclear. Though the statute provides for the appearance of witnesses at reviews,
some uncertainty prevails. This is particularly true in reference to the deceased child's parents.
5. Agencies were reluctant to share information. Though the statute provides for protection, liability concerns exist.
Particular frustration has been registered about the inability or refusal of some agencies who have dealt with the families of the deceased children to share information. Substance abuse and counseling agencies were cited. Recommendation: Clarify the confidentiality regulations to reassure the agencies.
6. Inconsistent use of the fataUty review report forms. Efforts to make documentation of reviews uni{orm prompted creation
of a standardized form for the review. However, the forms have not been used in a consistent manner; in addition, there is no consensus about their value. Recommendation: Review the forms. (The forms were provided with assurance from the statewide panel that appropriate revisions would be made after a trial period.)
7. Insufficient staff and funds. No resources were provided to fund the work of the local committees.
They have had to tum to one or another of the represented agencies to pay expenses.
-37-

Support for the fatality review process at the state level has come from staff in the Divisions of Family and Children Services and Public Health. Federal grants have been used for training, travel and printing. Recommendation: Review the need for and the feasibility of a budget improvement recommendation/request.
8. Reluctance to criticize agencies involved with families. The Governor's Task Force Report (1989) suggested that one purpose
for a child death review team is to identify "flaws in the methods used by agencies when dealing with children." In many counties there is a reluctance to criticize agency involvement with a child or family to determine if the involvement was appropriate and if anything could have been done to prevent the child's death. There is a need to develop an atmosphere of trust and diminish the reluctance to objectively assess what agencies do or do not do with clients. Recommendation: Continued training and technical assistance regarding intent of fatality review. Focus on need to identify gaps and flaws in service delivery in local/state systems and not to assign blame.
-38-

.Ezamples of Action Taken as a Result of Chi'/d Fatality Reviews
The Statewide Panel became aware of several specific actions resulting from local committee reviews. These actions included:
0 The requirement of autopsies on infants prior to assigning SIDS as the cause of death made a difference in at least one case. In this case, an autopsy did not confirm SIDS, giving the district attorney grounds to prosecute for homicide. Historically, SIDS might have been the cause automatically assigned to this unexplained infant death.
0 Community concern led to installation of a traffic light at a dangerous intersection, where a number of adolescents had been killed.
0 A county review was the impetus for closer state scrutiny of rules regarding the certification of lay midwives. The rules were revised to require that all midwives be nurses.
-39-

STATEWIDE PANEL RECOMMENDATIONS
In addition to problems identified and recommendations with the review process, there were several other recommendations. These are the result of the Statewide Panel's review and discussions and are, to a degree, distinct from recommendations presented above. The Panel identified other aspects of the review process where change or improvement may be appropriate.
0 Transmission of medical examiner/coroner reports regarding child deaths:
Recommend that the procedures be reviewed and, if appropriate, be
changed to assure that all reports regarding unexpected or unexplained
children's deaths be forwarded from the Georgia Bureau of Investigation
(when appropriate) to the protocol committees. Based on information from some counties, it appears some children's deaths are not being reviewed because protocol committees are not being informed. (At the time of the report, this recommendation had been implemented.) 0 Death or incident scene investigations: Recommend that alematives be pursued to increase the capacity for a scene investigation in the unexpected or unexplained deaths of children.
Clarification of "what is IBlezplained and unexpected": Recommend that
strong assurance and documentation of cause are present when a child's death, particularly at a younger age, is excluded from review on the basis
of medical certainty.
(Deaths which are not adequately explained or not expected should be subject to full inquiry, including consideration of an autopsy.)
-40-

SPECIFIC RECOMMENDATION FROM STATEWIDE PANEL
An early analysis of the data indicated that almost thirty percent of the deaths reviewed were the result of accidental causes. The vast majority of these deaths were from vehicular accidents. In most cases the absence of seat belts or other restraints was a factor noted in the review information.
As a result of this finding, the State Panel strongly recommends modifications to the Georgia Code related to the requirement to utilize seat belts and children restraints in motor vehicles. At least eight children under age 3 and thirty nine older children died in automobile collisions, many of whom might be alive if properly restrained.
The Panel believes that some civil and criminal penalties should be considered and the failure to use a seat belt or child restraint should be a traffic offense in and of itself. The Panel members believe that law enforcement officers should be directed to cite those who break the seat belt and/or child restraint laws, even if that is the only offense. The Panel also believes that routine checks and observations by law enforcement officials should be made to assure the utilization of seat belts and child restraints.
NOTE: This recommendation was developed with the consensus of the Statewide Panel and was presented to the Governor prior to the 1992 session of the Georgia General Assembly.
-41-

CONCLUSION
The first annual report represents a milestone in Georgia. It is a precedent that demonstrates public policy which has a growing commitment and focus on the needs of children and families in the state. The fatality review process is one component in a multi{aceted array of programs and services needed to assure a better future for all children.
The inception of the fatality review legislation has enhanced the state's ability to better understand many of the factors associated with children's deaths. The information and data in this report will contribute to an improved identification and assessment of risk markers common to unexpected or unexplained deaths. In tum, this will hopefully prompt creative responses designed to prevent unnecessary children's deaths.
The combined efforts of citizen advocates, legislators, state agency personnel and the Governor's office resulted in the implementation of the child fatality review. These same groups now have the opportunity to influence resource allocation, health and safety education, and prevention strategies. Even though only one element of many, the fatality review is a pivotal component which can have untold impact on the lives of children in Georgia.
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APPENDICES

Apptndix A Child Fatality Revitw flow Chart

DEATH

Unuptcted or unuplained A.G. opinion: agts 0 to 18

LAW Entorcti.tnt or othtr r,port to Corontr/ft,E.

DC~ 4H6-24

fttdicil Ex~iner/ Corontr ordtrs
Inquiry

Inquiry Report

OCGA 45-16-32

OCGA 45-16-24 19-1-3

DFACS or CAPC

G.B.I.

CAPC Meets and Advises

20 days CAPC report

15 days

District Attorney

Any of 8 causes of death
OCGA 19-1-3

HOH: 1. A.G. : ATTORNEY GENERAL
2. CAPC: cCHoInLnDrmABEUSE PROTOCOL
3. OCGA : OFFICIAL CODE OF GEORGIA ANNOTATED

State1.1idt Panf!

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APPENDIX B

Page 1 of 2

Georgia Child Death Review Team: Form ti l: Child and Death Information County: ________________ Date of team review: _______

I. Victim Identification l)Name ________________________,_.

l) Case ti

(last)

(first)

(m)

3) DOB __/ _ / ~ ) DOD_/_/ _ _ 5) Age_ 6) Sex 7) Race

8) SSNtl _______ 9) Educational level

II. Significant Others

Name

Rltshp

!. ____________ - - -

2. ____________ - - -

3. ____________ ---

q _____________ ---
5. ___________

6. ____________

In.
Age Sex Race Home

Educo1tional
llitl

III. Death Information

1) Category of Death(as determined by Medical Examiner, Coroner or Physician)

a) Medical causes, Diseases or Natural causes

SIDS?

b) Homicide

Child Abuse or Neglect? Suspected_, Confirmed

(if yes for any item in b, then complete item Vil

c) Suicide

d) Accident

e) Undetermined f) Pending _

2) Caalu_se_o_f _de_a_th_(_as_s_ta_te_d_o_n _th_e _d_ea_th_c_e_rt_if_ic_at_e)______________

b) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

c) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

3) Circumstances of Death: Place of Death County of death _______________ Time of Death

a) Child abuse/neglect related? (Confirmed/Suspected/No/Uk)

(if Confirmed or Suspected then complete item VI)

bl Alcohol or substance abuse related?

(Y/N/Ukl

cl Trauma?

(Y/N/Uk)

d) AdeQuate care/supervision at time of death?

(Y/N/Uki

e) Was death witnessed?

(Y/N/Uk)

Narrative:

4) Medical Examiner/Coroner Reoort: Deceased weight (lbs)

height

a)Autoosy

(YIN/Uk) Findings: _______________________

b)Drug/Tox Screen (YIN/Uk) Findings: _______________________

c)STD screen

(YIN/Uk) Findings: ______________________

d)Death Scene Invst(Y/N/Uk) Findings: _______________________

IV. Maternal Information: Age

Race

Maiden Name

~ of Children Alive/Dead

/

Marital Status ( SIM/ Dv-s/ othr )

Employed, (Y/N/Uk)

WIC? (Y/N/Ukl

Medicaid, (YIN/Uk)

AFDC? (Y/N/Uk)

Education level

V. Complete followino for victim< l Delivery Hospital

Birth wt.(lbs) ____ Prematurity or LBW? (Y/N/Uk) if yes then Weeks Gest.

Prental exposure to alconol/drugs/tobacco (Y/N/Uk) 11 y specify

Maternal Prenatl care (Y/N/Uk) tt of v1s1ts

tr1mest~r of Isl ~1s1t (1/213)

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Form N 1: Child and Death Information

page 2/2

VI. Child Abuse and Homicide Perpetrator information

Age ____ Race ____ Sex

Relationship

Prior criminal history

Prior history of child abuse or neglect

History of alcohol or substance abuse

Prior history of domestic violence or other violence

Is alleged perpetrator a caretaker of other children

(Y/N/Uk.) (Y/N/Uk) (Y /N/Uk) (Y/N/Uk) (Y/N/Uk)

VII. Child Death Factors (all pertain to deceased unless specified otherwise)

Please explain any marked yes

Ex p1an a ti on

a)HX of Abuse/Neglect of deceased (YIN/Uk) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

b) Disability or handicap

(Y/N/Uk) ____________________

c) Significant medical condition (YIN/Uk) ____________________

d) HX of abuse/neglect in siblings(Y/N/Uk) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

e) HX of family violence

(Y/N/Uk) ____________________

f) Hx of serious injury

(YIN/Uk) _____________________

g) Unexpected death of a sibling (Y/N/Uk) ____________________

h) Alcohol/drug abuse by deceased (YIN/Uk) ____________________

i) Prenatal exposure drugs/alcohol(Y/N/Uk) _____________________

VIII. Agency lnvolvement(with victim or family; check all that apply)

Services

Agency

Before After Agency

Appropriate?

Name 1. DFCS

~ Death Contacted?

Y/ N/ Undt

a. CPS

b. Placement

c. Payment/Assistance 2. Police/Law Enforcement

3. District Attorney

4. Courts (specify which)

a

5. Public Health

6. Mental Health

7. Hospital/ Clinic

8. General Medic.al Care

9. Military

10 CASA

11. School 12. ME/Coroner

13.

For any Agency involved fill in Form~ 2: Aoencv form (or agency specific form)

IX. Prevent.ability
l. The death was prevent.able as determined by the death review team (Check one) a. Definitely ( ) b. Prob.ably ( ) c. Probably Not ( d. Definitely Not C ) e. Undetermined ( )
2. If a orb, how could the death have been prevented?

X. Recommendations

Xl_:_~t__t_.l-.f.!!_ments Death Certificate Aoency rorms (~ & .agencies

Autopsy rc>port -48-

Form~ 2 (Ill 0 t Iler

Pagel

Georgia Child Death Review Tea: Form M 2 Aoency Information County: _________________ Date of team review: ________

I. Victim Identification 1) Case M _ _ _ _ _ _ 2) Name

II. Agency Information:

1) Agency

2) Agency Case M

3) Agency Contacts with Victim and/or Family

Dates

Reason

Services Provided

a. Open

Close

.

b. Open

Close c. Open

Close d. Ooen

Close

e. Open

Close

Preventability of this death a. Definitely b. Probably c. Probably Not d. Definitely Not e. Undetermined
2. If a orb, how could the death have been orevented?

3. Preventabilty of similar future incidents:

4. Recommendations:

The Child Fatality Review Law Respondents were asked if they were aware of the 1990 addition of child fatalities
to the provision of the Child Abuse Protocol system. Table 19 shows the respondents of each county agency by county population. As was the case with the DFCS offices, the district attomeys (not shown) were also unanimous in their knowledge of the new provision.
A large percentage of sheriffs and city police departments were not aware of the new law.
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