Pilot CWS-R-SAP – v. 1 Current CWS, 11.14. Causes of Child Fatalities


Pilot Child Welfare System Redesign

Strategic Action Plan


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11.14. Causes of Child Fatalities


The following chart has been created from data in the annual Oregon Child Welfare Data Books for the years 2009 through 2019.

Causes of Child Fatalities Chart
Causes of Child Fatalities Chart


The data on the number of child deaths due to neglect is represented by the blue columns on the chart. Except for two years between 2009 and 2019, the most frequent cause of death was from neglect.


The orange columns represent the number of child deaths due to physical abuse. 2011 reported more than 3 times the number of deaths due to physical abuse than neglect. 2011 and 2012 are anomalous years in that the statistics do not follow the pattern of all the other years from 2009-2019. Pattern anomalies are often opportunities for research into underlying causes for the difference. However, in this case, no anomalies in other factors, such as perpetrator, age of child, or involvement with DHS could explain the increase in physical abuse deaths for those two years.


The gray columns represent the number of child deaths due to both physical abuse and neglect, which fluctuates throughout the years, but never reaching a major cause role in the deaths of children.


The total number of child deaths per year is the sum of the blue, orange, and gray columns.




Goal: Every person in Oregon has heard about the Oregon Child Welfare System and knows what to do if they see or suspect child abuse or neglect taking place – and every report of child abuse or neglect results in an assessment at some level, depending on the severity of the abuse or neglect.


Action Step 11.14.1: Start email, letter, poster, and flyer campaigns throughout the neighborhoods, cities, counties, and the state, with varying themes and target audiences:

  • help is available for parents who are having trouble coping with their child
  • child abuse and neglect are not “family matters” they are crimes – if you see something, report it
  • “It takes a community to protect and support a child” – there is no “ownership” of a child
  • neighbors can offer assistance to parents who are struggling; neighbors can offer to let their child play with another’s child or their child can come over and help you bake some cookies
  • have a parent-to-parent talk with your neighbors
  • at school, have a large placard that provides a phone number for the child to call to get help – and ensure that every child who calls that number actually receives help – all calls from a child are automatically screened-in
  • at school, have a large placard that explains that their life matters, that help is available, to give themselves another day, and to call the phone number to receive help and hope


Action Step 11.14.2: Every child abuse report that includes a child 0-5 years old in the family is automatically screened-in for CPS assessment.


Action Step 11.14.3: When conducting the initial assessment, ensure that every child in the family (not just the child in the child abuse report) is seen individually, has their picture taken, and has a private conversation – expand CPS guidelines to look for signs of neglect in addition to physical abuse, sexual abuse, and emotional abuse.


Action Step 11.14.4: Ensure that weekly, unannounced, random visitations are held with the family and that every child is visited at every visit – follow-up on excuses for a child’s absence.


Action Step 11.14.5: Compare pictures and notes with the previous visitations to determine if there is a pattern that may indicate neglect; for example, the child is wearing the same clothes in every visit, regardless of the day of the week of the visit; the child looks thinner or less active; the child’s story changes from the previous visit. Include all suspicions and observations in the child’s record and follow-up on any suspicions of child abuse or neglect.


Action Step 11.14.6: When a parent leaves the hospital with a new infant, include a discussion with both parents about the fragility of children and the heavy responsibility of a parent to protect and nurture the child. Include a brochure in their release packet with information about support services and groups for parents who need help coping with their child, are in a domestic violence situation, are in a volatile relationship, or just unable to cope.


Action Step 11.14.7: Every child abuse report from a parent or a child is automatically screened-in for assessment.


Action Step 11.14.8: At the main bulletin board at the workplaces, in addition to OSHA and other mandatory announcements, include a mandatory announcement targeted to parents about help and resources that are available to assist them when there are difficulties with coping with their child. This announcement should be an official Oregon State announcement (until there can be an official Federal announcement), similar in importance to the OSHA announcements, that is mandatory to be displayed in every Oregon business and organization that has employees or volunteers.


Action Step 11.14.9: Create a Speakers Bureau, with speakers from every community volunteering to talk with local businesses, nonprofits, civic groups (e.g., Eagles, Rotary, Elks, etc.), faith groups, and individuals and to distribute brochures with guidance for parents with children about available help.


Action Step 11.14.10: Enlist the partnership of local and state nonprofit organizations and civic groups to support the work of the Child Welfare System, spread the word about services available to parents and children, and offer their services and programs that are aligned with the Child Welfare System’s purpose. Ensure that all such organizations are fully vetted and that any organization member who is authorized to be with a child has been fully vetted with a complete background check. Vetting and background checks are to be repeated annually for every volunteer, for the children’s safety.


Action Step 11.14.11: Every hospital gives a pamphlet or brochure to all parents of newborns: “Sometimes It’s Hard to be a Parent” or “Help is Available If You Need It.” Give to all parents, no bias or targeting.


Action Step 11.14.12: Hospitals compare new parents against records of prior interactions with CWS. CPS pays a “welcome visit” to the home of the new child.


Action Step 11.14.13: CWS send welcome letter to all parents saying resources are available to them, no bias and no targeting.


Action Step 11.14.14: Well baby visits: have pamphlets available where parents can discreetly pick them up.


Action Step 11.14.15: Campaigns about services available to parents: invest in pamphlets and brochures to save a child from abuse and neglect .


Action Step 11.14.16: Have a separate support line for parents who are overwhelmed, suffering domestic violence, or escalating anger or frustration toward the child.


Action Step 11.14.17: Schools post notes with phone number for children to call – ensure that all calls made by children are screened-in.


Action Step 11.14.18: Federal level make templates available to the states and tribes.


Action Step 11.14.19: Oregon create their own pamphlets and brochures, based on the federal templates or their own design.


Action Step 11.14.20: Make federal grants available to pay for printing pamphlets and brochures.


Action Step 11.14.21: Search for Best Practices; the information is out there, but is not being heeded nor followed.


Action Step 11.14.22: Focus on prevention; learn from the data to prevent future occurrences.



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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