Pilot CWS-R-SAP – v. 1 Current CWS, 11.10. Child Fatalities


Pilot Child Welfare System Redesign

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11.10. Child Fatalities


From an Oregon Dept. of Human Services Critical Incident Review Team website:


“In recent years, many child fatalities investigated by DHS have been related to issues of neglect and parental substance use.  Current efforts are underway to establish consistent and up-to-date education and support for caseworkers when assessing and offering services to families where substance use is identified as a concern. Since 2017, youth suicide, chronic neglect, and safe sleep have been identified as systemic issues impacting the safety and well-being of children in Oregon who come into contact with Child Protective Services.”[1] [bolding added for emphasis]


The data from the annual Data Books provide the evidence of whether the “identification” of suicide, chronic neglect, and safe sleep in 2017 have impacted the statistics of child abuse and neglect. However, the following Critical Incident Review Team report states that the “safe sleep education” had not yet started as of May 2020:


“The CIRT recommends the Department continue with the implementation of a safe sleep education plan for child welfare staff. This plan includes providing education and coaching to all child welfare staff who come into direct contact with families. Education will include guidance for caseworkers around engaging in thorough safe sleep conversations and providing safe sleep education as appropriate to families any time there is a child under the age of one in the home. This mandatory training is scheduled to begin in May 2020.”[2] [bolding added for emphasis]


[1] Oregon Department of Human Services / Children / Critical Incident Review Team, https://www.oregon.gov/dhs/CHILDREN/CIRT/Pages/Prevention.aspx

[2] “Critical Incident Review Team Final Report, May 13, 2020,” Oregon Dept. of Human Services, PDF


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To submit questions or comments, please email Jo@Jo-Calk.com. I welcome all input, ideas, and suggestions. Thank you for caring for children.


Jo Calk