Pilot CWS-R-SAP – v. 1 Current CWS, 12. NCFRP – Spotlight – Oregon2


Pilot Child Welfare System Redesign

Strategic Action Plan


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12. NCFRP – Spotlight – Oregon2


The National Center for Fatality Review and Prevention provides “Spotlights” on each state. The following is from Oregon’s Spotlight.



Teams review unexpected deaths including homicides, suicides, accidents, unexpected natural deaths and deaths due to an undetermined manner to children less than age 18.



The purpose of CFR in Oregon is investigation, prevention, quality assurance, data collection and to provide services. This is the focus in statute. There is a shift on the state level to primarily a prevention focus. The local teams also work on prevention.


Annual Report

Annual reports on child death due to violence, maltreatment, suicide and injury are produced as part of an annual injury report that is produced by the injury epidemiologist. The report includes recommendations for prevention and policy and is linked to the five-year state prevention plan.


Prevention Initiatives

CFR findings have influenced policy changes on the state level. There was a change in the child abuse statutes to eliminate the religious beliefs exemptions for homicide cases. Statutes to prohibit children from riding in the back of pickup trucks, requiring helmets when skating, riding scooters and skateboards, booster seat requirements and the prohibition of the resale of older cribs that are dangerous in second-hand stores have been passed. Statute was passed to outlaw toy lighters and mandate fire safe cigarettes.

Additionally, prevention information is provided to all new parents through the state newborn handbook including information on safe sleep environment, home safety, and child passenger safety.

CFR findings have also implemented prevention initiatives at the local level. Examples include: The state developed a suicide prevention plan that is being implemented by local groups. Oregon coastal communities implemented a prevention program to reduce the number of deaths due to logs rolling over kids playing on driftwood. Clackamas County established a lifeguard at two public swimming beaches on the Sandy River. Safe Kids coalition continue to partner with local teams to distribute helmets and safety seats to low income families with children. A window falls prevention alliance has developed a communications strategy to prevent window fall injuries among children.



Oregon CFR has meeting, confidentiality, and child/infant death investigation protocols in place.



Training on the CFR process is presented by DOJ staff for Victim’s Assistance staff working for local DAs. Training on using the national data entry system was provided to local teams in 2013.


Last Updated: February 2019[1]




Action Step 12.0.1: Follow the guidance provided in the Child Maltreatment Fatality Reviews: Learning Together to Improve Systems That Protect Children and Prevent Maltreatment report, available in PDF format.[2]


[1] The National Center for Fatality Review and Prevention, https://www.ncfrp.org/cdr-programs/u-s-cdr-programs/spotlight-oregon/, accessed 8/13/2020

[2] Covington, T and Collier A. (2018). Child Maltreatment Fatality Reviews: Learning Together to Improve Systems that Protect Children and Prevent Maltreatment. National Center for Fatality Review and Prevention. www.ncfrp.org


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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