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Office of Injury Prevention

Child Fatality Review

Every time a child dies in Arizona, the death is scrutinized by a panel of experts. Pediatricians, social workers, attorneys, advocates, law enforcement and others volunteered more than 5,700 hours to investigate the 862 child deaths in 2010. A number which represents fewer children than died in 2009 (947) and 26% fewer than died in 2005 (1,148).

The 18th Annual Child Fatality Review Report (required by statute), published by the Arizona Department of Health Services on behalf of the Child Fatality Review Team includes recommendations for elected officials, other policy makers, parents and the Arizona public.

One of the findings in this year's report calls to reduce the number of pedestrian deaths. ADHS is working with counties around the state and local school districts to establish safe routes to school. Other recommendations include ways to deaths tied to home safety, substance abuse, infectious disease and maltreatment.

Annual Reports

County Reports

What is the Child Fatality Review?

Arizona's Child Fatality Review was created in 1993 (A.R.S. § 36-342, 36-3501-4) and data collection began in 1994. Reviews of child deaths are completed by 12 local child fatality teams located throughout Arizona. The state team provides oversight to the local teams, produces an annual report summarizing review findings, and makes recommendations regarding the prevention of child deaths. These recommendations have been used to educate communities, initiate legislative action, and develop prevention programs. The Arizona Department of Health Services provides professional and administrative support to the state and local teams and analyzes review data.

Why is this program important?

The unexpected death of a child is a tragedy and a devastating loss for family, friends and the greater community. Despite the heartbreak, a child's death can bring a small measure of meaning to other children at risk when it is carefully examined to better understand how and why it happened with the intent to prevent future deaths and improve the health and safety of all children.

What are the goals of this program?

The goal of the Child Fatality Review is to reduce preventable child fatalities through systematic, multidisciplinary, multi-agency, and multi-modality reviews of child fatalities in Arizona. This is accomplished through interdisciplinary training and community-based prevention education and through data-driven recommendations for legislation and public policy. Recommendations incorporate the Spectrum of Prevention:

Spectrum of Prevention
Influencing Policy & Legislation
Changing Organizational Practices
Fostering Coalitions & Networks
Educating Providers
Promoting Community Education
Strengthening Individual Knowledge & Skills

Created by Larry Cohen, Contra Costa Health Services Prevention Program.

How are child fatality reviews conducted?

When a child younger than 18 years of age dies in Arizona, a copy of the death certificate is sent to the appropriate Local Child Fatality Review Team. The local team coordinator or chairperson then requests relevant documents which may include the child's autopsy report, hospital records, Child Protective Services records, law enforcement reports, and any other information that may provide insight into the death. If the child was younger than one year of age at the time of death, the birth certificate is also reviewed. Legislation requires that hospitals and state agencies release this information to the Child Fatality Review local teams. Team members are required to maintain confidentiality and are prohibited from contacting the child's family.

What has this program achieved?

Many communities across Arizona have used report findings and recommendations to educate the public on ways to improve the safety and health of children and have supported changes in policy and legislation to reduce childhood deaths. The Child Fatality Review State Team's annually published report outlines actions that each of us can take to prevent the un-timely deaths of Arizona's children.

Local Team Resources: