Pilot CWS-R-SAP – v. 1 Current CWS, 8. National Center for Fatality Review and Prevention

Pilot Child Welfare System Redesign

Strategic Action Plan

 

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8. National Center for Fatality Review and Prevention

 

Child Abuse and Neglect

Infants & Children, Ages 4 & Under

Published October 2018[1]

 

The National Center for Fatality Review and Prevention collects child abuse and neglect information from the NFR-CRS [National Fatality Review Case Reporting System (NFR-CRS) is a standardized, web-based reporting tool and database used by state and local CDR and FIMR teams to record, analyze and report on the case information and findings from their reviews.[2]]. Since 2004, there have been 3,216 child abuse and neglect deaths of infants and children, ages 4 and under, reviewed by teams.

 

Race:

  • 57% White
  • 33% African American
  • 10% Other / Multi-racial

 

Sex:

  • For every 10 child abuse and neglect deaths, 4 are girls and 6 are boys

 

Age:

  • Infants account for 52% of child abuse and neglect deaths ages 4 and under
  • 52% under one year old
  • 48% 1 – 4 years old

 

Circumstances Surrounding Deaths:

  • 8 in 10 resulted in Child Protective Services (CPS) action due to the death
  • 7 in 10 occurred in the child’s home
  • 5 in 10 had evidence of prior abuse
  • 4 in 10 had history of child maltreatment prior to death
  • 2 in 10 had an open CPS case with child at time of death
  • 1 in 10 were placed outside of home prior to death

 

Person Responsible:

  • Median age – 25 years
  • 6 in 10 – Male
  • 6 in 10 – Biological parent
  • 1 in 10 – Mother’s partner
  • 1 in 10 – Other relatives
  • 1 in 10 – Others

 

Of deaths reviewed, about 7 in 10 were abuse deaths.

  • Of those, 10 in 10 were due to physical abuse and
  • 6 in 10 were due to abusive head trauma

 

Nearly 3 in 10 were neglect deaths.

  • Of those, 7 in 10 were due to failure to protect from hazards and
  • 2 in 10 were due to failure to provide necessities.

 

Child Maltreatment Fatality Reviews:

An analysis from 2014 of 2,285 maltreatment deaths reported to the NFR-CRS found the number of recommended system changes or planned prevention actions to be disappointingly small.

In September of 2017, the NCFRP convened a meeting of 23 national thought leaders and a child welfare expert from the United Kingdom to develop strategies that can improve review teams’ skills in moving from the case review to action.

This Guidance[3] provides recommendations to help improve child maltreatment reviews with a special focus on being more effective in moving from the case discussion to systems improvement to better protect children and prevent other deaths.

 

From the CAN Guidance PDF:

“This guidance will provide you with information to assist you in conducting high quality case reviews of child maltreatment fatalities. The purpose of the guidance is to help ensure that your reviews lead to a better understanding of the circumstances and causes in the deaths you review and ensure that you translate this information into systems improvements and actions that will prevent other deaths and serious injuries.”[4]

“In addition to improving the response to maltreatment deaths, many states have broadened the scope of their reviews to include improving their understanding of unintentional injuries, suicides, other homicides and many preventable natural-cause deaths, all to improve agency systems and prevent these deaths.”[5]

 

“Table 1 is an analysis from 2014 of 2,285 maltreatment deaths reported into the National CDR Case Reporting System. The analysis found that the number of recommended systems changes or planned prevention actions was disappointingly small, ranging from none to only a little more than half.”[6]

Table 1: Recommendations Made by CDR Teams Following Maltreatment Case[7]
Type of action Number of cases with recommended or planned action Number of cases with implemented action
Agency Systems
New policy 67 5
Revised policy 50 5
New program 37 1
New service 45 1
Expanded service 39 2
Law/Ordinance
New law or ordinance 21 0
Amended law or ordinance 12 1
Enforcement of law or ordinance 35 5
Primary Prevention
Media campaign 116 11
School program 62 2
Community safety project 85 11
Provider education 108 17
Parent education 192 45
Public forum 43 1
Other 56 1
Environmental Modification 16 0
Other 36 1
N= 2,285 maltreatment deaths reviewed

 

“In 2015, the final report from the federal Commission to Eliminate Child Abuse and Neglect Fatalities included a recommendation that states identify and analyze all of their child abuse and neglect fatalities from the previous five years to identify under what circumstances children died from abuse or neglect, protective factors that may prevent fatalities from occurring, and agency policies and practices across multiple systems that need improvement to prevent fatalities. Further commission recommendations describe specifics of state maltreatment prevention plans to be developed after these reviews are completed.”[8]

 

“These recommendations were addressed in the U.S. Bipartisan Budget Act of 2018 through the new Families First Prevention Services Act (FFPSA). This federal legislation includes provisions specific to child abuse and neglect fatalities and CDR including that:

  1. States must document steps taken to track and prevent child maltreatment deaths by including a description of the steps the State is taking to compile complete and accurate information on child abuse and neglect deaths, including gathering relevant information on the deaths from entities such as State vital statistics department, child death review teams, law enforcement agencies, offices of medical examiners or coroners; and
  1. Provide a description of the steps the state is taking to develop and implement a comprehensive, statewide plan to prevent the fatalities that involves and engages relevant public and private agency partners, including those in public health, law enforcement, and the courts.”[9]

 

It is important to emphasize that despite best efforts to develop one standard set of guidelines, the experts determined that there is not, nor should there be, a prescriptive model. Rather local and state contexts and current practices should be considered in improving review processes to improve outcomes. It is hoped that you will adapt the information presented here to improve your own systems.[10]

 

“It [is] imperative that these efforts translate into sustained actions to keep children safe, healthy and alive.”

 

The Internal Audit Approach The Systems Approach
Human error is viewed as the cause of accidents Human error is viewed as a symptom of trouble deeper inside the system
To explain failure, you must fully investigate the failure To explain failure, do not try to find where people went wrong
You must find people’s inaccurate assessments, wrong decision, bad judgments Find how people’s assessments and actions made sense at the time, given the circumstances that surrounded them

“An important distinction between CDR and internal agency audits is that CDR is not focused on agency or individual worker performance. It is a systems approach that, while it may discuss behaviors of an agency or person, it does so to highlight the factors in the system that contributed to those actions.”[11]

 

Best Practice Model: Tennessee

Tennessee has a comprehensive CDR program based in their state health department, with multidisciplinary county teams reviewing all preventable deaths. They also have a review system called Children’s Services Systems Analysis, administered by the Department of Children’s Services (DCS). This model has four regional teams conducting analyses of deaths of children in state custody or with a DCS case within 3 years from the death, or whose death is substantiated for abuse or neglect. They also review some serious injuries from abuse or neglect. The process uses systems analysts to construct a case file and conduct the reviews. They are assisted when necessary by a team of nurse consultants. Following the systems analysis, a state Safety Action group discusses findings with leadership and does a formal hand-over to the state quality improvement office. Tennessee uses a Safe Systems Improvement Tool to summarize findings. This SSIT is now in use in other states as well.” [12]

 

“In addition to maltreatment review models, many states conduct reviews of other types of deaths. These include fetal and infant mortality reviews, maternal mortality reviews, overdose, suicide and domestic violence reviews, and reviews of deaths of vulnerable adults. It can be helpful to work to improve coordination and collaboration across these systems in your state or community.”[13]

 

Best Practice Model: The Safety Science Approach

The Safety Science Approach

Applying a safety science framework to child fatalities is a new and promising area. Safety science is an interdisciplinary science that draws on psychology, engineering, architecture/design and many other related fields. It is an approach that concerns itself with understanding how humans interact with and within complex systems so those systems can be made more safe and reliable. Safety Science began as an approach to understand the complex set of systems involved in plane crashes: from engineering, weather, pilot behavior, traffic control, etc. The model has expanded to the health care industry and is routinely used to systematically examine medical errors with “the aim to make it harder for people to do something wrong and easier for them to do it right … More commonly, errors are caused by faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them.”1

The Commission to Eliminate Child Abuse and Neglect Fatalities recommended in their final report that safety science be explored as an approach to better understand and prevent fatalities: “Child protection is perhaps the only field where some child deaths are assumed to be inevitable no matter how hard we work to stop them. This is certainly not true in the airline industry, where safety is paramount and commercial airline crashes are never seen as inevitable.”2

The approach systems take to reviewing and learning from critical incident can have an outsized impact on improvement and reliability. For example, when a child welfare system’s response to a high-profile death results in blame, as is commonly seen, professionals in that system can become more risk averse and fearful. The numbers of children removed increases and reunifications decrease. This can result in overwhelming workloads and high staff turnover. In addition, as other safety critical industries have recognized, a culture of fear and blame does not promote learning from error and can result in decreased organizational effectiveness and compromised safety.

Safety science gives systems a framework for review processes that: 1) Understand the inherently complex nature of child welfare work and the factors that influence decision-making; 2) Acknowledge staff decisions alone are rarely direct causal factors in a child’s death, but these decisions may affect the overall trajectory of well-being for a child or family and be an influence, among many influences, of poor outcomes; and 3) Provide a safe and supportive environment for professionals to process, share, and learn from child deaths in an effort to best support quality case management practices and influence increasingly safe outcomes for children.

For the past several years, Casey Family Programs has supported efforts to implement safety science principles in Child Welfare in several jurisdictions through peer visits to the TN Department of Children’s Services as well as through technical assistance and expertise from consultants at Chapin Hall at the University of Chicago and Collaborative Safety, LLC.

The interest in this approach is growing and a number of jurisdictions have embraced strategies and tactics from safety science, as adapted from other safety critical industries, in an effort to improve their systems. Among these strategies is the Safe Systems Improvement Tool (SSIT). Arizona, Wisconsin, and Tennessee use SSIT and the systems-focused approach developed in Tennessee to learn from child deaths and inform prevention strategies.

Although still in its infancy as a tool for fatality reviews, there is promise that safety science can be adapted to help teams better identify systems issues and develop solutions to better protect children.

[1] Institute of Medicine. (1999). To err is human: building a safer health system. Available at: http://www.nationalacademies.org/Err-is-Human/To%20Err%20 is%20Human%201999%20%20report%20brief.pdf

[2] Commission to Eliminate Child Abuse and Neglect. (2015). Within our reach: a national strategy to eliminate child abuse and neglect fatalities. Government Printing Office, Washington DC. Page 11.

 

Comparison:

The total number of people killed in airplane crashes EVER: “A total of 1,918 accidents involving jet airliners of all types (including cargo), killing 29,646 aboard and 1,216 on the ground.”[14] [bolding in the article]

At least since 1959, a total of 30,852 people have died in airplane crashes. This averages about 5,144 deaths per decade, or 514 deaths per year. Please note that, although the number of people flying on airplanes increases every year, the number of deaths has been decreasing.

Compare this against child abuse and neglect deaths in ONE year: “As Many as 8 Children Die of Abuse and Neglect Every Day: Report. According to a new report, about 1,500 to 3,000 children in America die from abuse and neglect each year, but a federal agency said the deaths can be prevented.”[15] and “1,770 children died from abuse and neglect in 2018.”[16],

514 airplane crash deaths per year versus 1,770 child abuse and neglect deaths per year. Sufficient cause to investigate the Safety Science Approach.

 

Recommendations:

Action Step 8.0.1: Assign a business systems analyst to review every monthly and annual report from the state’s Child Welfare System and every post-mortem for proactive steps to reduce child abuse neglect and fatalities with a goal toward elimination of child abuse and neglect

 

Action Step 8.0.2: Explore implementing – or recommending implementation of – the Safe Systems Improvement Tool (SSIT) developed by Tennessee[17]

 

Action Step 8.0.3: Explore implementing – or recommending implementation of –the Safety Science Approach the airlines use, to look at all variables and develop proactive measures to avoid repetition of the patterns of child abuse and neglect deaths

 

Best Practice: Fatality Reviews

“A number of criteria, when present, ensure a quality team discussion as well as ensure that the reviews move from discussion to action. These criteria were generated by the national thought leaders based on practices from the field.

  • Reviews should be family-centered and child-focused, while at the same time presenting learning opportunities for agencies.
  • Reviews should include the telling of the child’s life story—not just the death event—and include information from a broad ecological perspective.
  • Reviews should be objective, forward-thinking, and not punitive towards agencies.
  • When possible, the facilitator of reviews should be independent from an involved agency.
  • Reviews should have a multi-systems focus, including broad team membership, case information from many sources, and findings and recommendations that address a broad array of systems.
  • Case selection should encompass a broad definition of maltreatment.
  • Case discussions should be systematic and standardized.
  • The focus of the reviews should be on risk and protective factors, systems issues, recommendations, and plans of action.
  • The expectation of every review is that it will lead to action. The actions will engage a broader set of partners than those participating in the review. [18]

 

Best Practice: Focus Reviews

“To help ensure that their reviews remain child focused, one state always displays the child’s photo on a screen during their discussion.”

 

Child Maltreatment Fatalities Underreported

“Numerous studies have demonstrated that child maltreatment fatalities are under-reported by as much as two to three times the actual number in state and national reporting systems. There are numerous reasons for this in any jurisdiction, but they may include:

  • Only deaths substantiated as abuse or neglect using definitions from child welfare civil and criminal law are counted.
  • Only deaths in which the death certificate lists homicide or child maltreatment are counted.
  • Multiple data sources are not used to find and classify the deaths.
  • Neglect deaths are often not identified and instead classified as unintentional accidents, even when egregious acts of poor supervision may have contributed to the death. The more obvious neglect deaths, such as starvation, are much easier to define than are neglect deaths due to poor supervision, e.g. leaving a toddler unattended near a swimming pool. Other factors are often considered before neglect is classified as a cause of death, such as caregiver substance use. [A] compelling case for having an expansive case definition for identifying deaths for maltreatment reviews. By expanding case definition to include circumstances beyond deaths known to CPS or substantiated, the likelihood that your team will find more maltreatment cases is greatly increased.”[19]

 

Number of Maltreatment Deaths Reported by NCANDS and by Selected State CDR Reports
 

State

National Child Abuse and Neglect Data System (NCANDS) State Annual CDR Report  

Year for Data

Arizona 11 51 2008
California 30 133 2001
Florida 156 192 2009
Georgia 60 77 2009
Iowa 6 7 2007
Kansas 10 13 2008
Kentucky 22 28 2008
Minnesota 16 19 2001
Missouri 39 109 2009
Nevada 17 37 2008
New Jersey 29 30 2008
Oklahoma 26 50 2006
Oregon 18 20 1999
Pennsylvania 40 98 2009
Washington 36 165 2001
TOTAL 516 1029

 

Best Practice: Review Population

In addition to including all children who have come in contact with CWS:

  • “Plus, all fatalities in which the cause or manner was accident, homicide, suicide, or undetermined.
  • Plus, all natural causes of deaths of children at least under the age of five.”[20]

 

“At a minimum the following four sources of records should be consulted:

  • Records from the medical examiner/coroner/pathologist
  • Medical records
  • Law enforcement reports/records
  • Child welfare records including past and current history on child, caregivers, and person supervising child at time of death

 

“Your review will be even richer if you have access to the following:

  • Interviews with family members
  • Names, ages, and genders of other children in home
  • Childcare Licensing investigative reports
  • EMS run reports
  • Emergency department reports
  • Child’s health history
  • Criminal background checks on person supervising child at time of death
  • Home visit records from public health or other services
  • Any information on prior deaths of children in family
  • Any pertinent out-of-state history”[21]

 

“The review is an opportunity to honor the child’s life and remember his or her past, while also moving forward with findings and recommendations to save other lives.”[22]

 

Best Practices: Recommendations

  • “Recommendations should be ‘SMART’ (Specific, Measurable, Achievable, Realistic and Timely).
  • Effective teams go through a systematic process to narrow the number of recommendations into a manageable number.
  • Don’t ignore the simple recommendation or low-hanging fruit. Recommendations do not always have to be sophisticated or complex.
  • New Hampshire has developed a simple checklist that their CDR team uses in reviewing every recommendation to determine if it meets their criteria for A.F.E.R.: Specific, Acceptable, Feasible, Effective & Efficient, and Risk Free.
  • It is important in maltreatment reviews that your purpose is not limited to developing primary prevention recommendations but also that you focus on improving counting of maltreatment and improvements to systems to keep children safe and protected.
  • Delaware … holds a day-long annual meeting of key stakeholders including agency decision makers. … The constellation of findings from all reviews is presented in an organized framework. Then working groups develop recommendations and an action plan for their set of findings. … This plan can then be monitored. Each year now, Delaware includes a review of the past year’s recommendations, actions taken and problems/solutions in following through.
  • The Michigan State CDR Board maltreatment review team (serving as the state Citizens Review Panel for Fatalities) found that when they began organizing their findings and developing SMART recommendations in a systematic way, state agency leaders were more receptive to their reports. In a published study, it was reported that the CRP reviewed 186 deaths and identified 264 findings in 27 issue areas during 1999-2001. These numbers decreased to 172 findings in 27 areas in 170 deaths reviewed in 2002-2004. This was a 35% decrease in findings and a 9% decrease in the number of deaths associated with those findings.
  • There were also improvements in areas affected by joint investigation protocols, birth match systems, and a ‘Safe Delivery Act’—implementing a safe surrender program—for newborns. … one reason these changes were implemented is that the CRP had a formal process in place to move from reviews, to recommendations, to state action, and then monitored state actions related to their recommendations.”[23]

 

Table 3: Examples of Teams Moving From Finding to Recommendation[24]
Finding # of Cases Recommendation
Deaths of infants in which there were more than six reports of neglect that were not accepted for investigation. 8 CPS to change their intake policy so infants with more than 3 reports are automatically screened-in for services. The policy will be changed by July 1, 2017.
Caregivers with CPS involvement in year preceding child deaths had not followed through on referrals for substance abuse treatment. 6 All cases where a biologic parent has current or recent substance use must be monitored by a case manager and their supervisor. Case Management tracking system will be modified within 180 days to reflect this change.
Caregivers had not been provided safe infant sleep education at local birth hospital 10 Local public health will create a certificate program to incentivize local hospital to become a certified safe infant sleep hospital by the end of 2016.
Caregivers with convictions of domestic violence left alone with children. 4 Improve sharing of information between police, CPS and home visiting through monthly multidisciplinary team meetings to improve service provisions for high risk families, including day care vouchers. These meetings will be implemented next month (June 2015).

 

Concerns and Recommendations From the Above Table:

Concern 1: Row 1 of Table:

Finding: “Deaths of infants in which there were more than six reports of neglect that were not accepted for investigation.”[25]

Action: “CPS to change their intake policy so infants with more than 3 reports are automatically screened-in for services. The policy will be changed by July 1, 2017.”[26]

Concern: Eight (8) infants died after each child had more than six (6) reports of suspected child abuse or neglect screened-out.

Infants have historically been reported as among the most abused, neglected, and killed age group, so why were ANY of the reports of a suspected infant abuse or neglect screened-out? These are specifically the FIRST reports that should be investigated, due to the historical data. The recommended “state action” of screening-in when there are more than three (3) reports is not sufficient for an infant. Reports of suspected child abuse or neglect of an infant should NEVER be screened-out.

 

Recommendations:

Action Step 8.0.4. Immediate and Short-term: Any report of suspected child abuse or neglect of an infant MUST be screened-in and given the highest priority for CPS investigation and assessment.

 

Action Step 8.0.5. Long-term: NO reports of suspected child abuse or neglect are to be screened-out. In other words, EVERY report of suspected child abuse or neglect MUST be screened-in.

 

 

Concern 2: Row 2 of Table:

Finding: Caregivers with CPS involvement in year preceding child deaths had not followed through on referrals for substance abuse treatment.[27]

Action: “All cases where a biologic parent has current or recent substance use must be monitored by a case manager and their supervisor. Case Management tracking system will be modified within 180 days to reflect this change.”[28]

Concern: Six (6) children died because Case Management did not conduct follow-up visits with a caregiver involved in a state-supported substance abuse program.

Why do Case Managers need to be told that follow-up is required? The substance abuse program is part of the Safety Program for the child and must be monitored to ensure adherence with the program as well as child safety.

 

Recommendation:

Action Step 8.0.6. Whenever a family is in a state-supported program, CPS MUST conduct weekly visitations to ensure program adherence by the family and the safety of the child.

 

 

Types of Deaths Reviewed in States[29]

Responses are not mutually exclusive for both Type of Death and Local/State level of Team. Fifteen states review 100% of child deaths.

Type of Death Local Review (n=36) State Review (n = 33)
Medical Deaths (not SIDS but includes infections, asthma, cardiac, cancer, etc.) 25 16
SIDS 34 28
SUID (SIDS, suffocation and undetermined infant deaths) 34 30
Unintentional Injuries 33 28
Homicides 32 27
Suicides 31 28
Undetermined 33 27
Abuse and Neglect 33 32
Opioid 28 21
Current or History of contact with Social Services 29 28
Child was a ward of the state 27 28
Child was a resident of another state/jurisdiction and death occurred in this state/jurisdiction 23 21
Child’s death occurred in a different state/jurisdiction and the child was a resident of this state/jurisdiction 17 12

 

Concern: State Investigate More Types of Death:

“Fifteen states review 100% of child deaths.”[30]

 

Recommendation:

Action Step 8.0.7. ALL states should review 100% of child deaths, particularly suicides, unintentional injuries, homicides, undetermined, and opioid.

 

References

[1] CAN-Related Deaths, National Center for Fatality Review and Prevention,https://www.ncfrp.org/resources/quick-looks/can-related-deaths/, accessed 8/13/2020

[2] Data Dissemination, National Center for Fatality Review and Prevention, https://www.ncfrp.org/resources/data-dissemination/, accessed 8/13/2020

[3] 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.orghttps://www.ncfrp.org/wp-content/uploads/NCRPCD-Docs/CAN_Guidance.pdf, accessed 8/13/2020

[4] 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.orghttps://www.ncfrp.org/wp-content/uploads/NCRPCD-Docs/CAN_Guidance.pdf, accessed 8/13/2020

[5] Ibid.

[6] Ibid.

[7] Ibid.

[8] 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.orghttps://www.ncfrp.org/wp-content/uploads/NCRPCD-Docs/CAN_Guidance.pdf, accessed 8/13/2020

[9] Ibid.

[10] Ibid.

[11] 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.orghttps://www.ncfrp.org/wp-content/uploads/NCRPCD-Docs/CAN_Guidance.pdf, accessed 8/13/2020

[12] Ibid.

[13] Ibid.

[14] How Many Plane Crashes Have There Ever Been?, Forbes Magazine website, March 1, 2017, accessed 8/15/2020, https://www.forbes.com/sites/quora/2017/03/01/how-many-plane-crashes-have-there-ever-been/#5442f7df7f34

[15] As Many as 8 Children Die of Abuse and Neglect Every Day: Report,  by DENISSE MORENO, March 17, 2016, The Epoch Times, https://www.theepochtimes.com/as-many-as-8-children-die-of-abuse-and-neglect-every-day-report_1995955.html#:~:text=As%20Many%20as%208%20Children%20Die%20of%20Abuse,revealed%20that%20the%20victims%20are%20overwhelmingly%20very%20young., accessed 8/15/2020

[16] Child Maltreatment Statistics in the U.S., American Society for the Positive Care of Children, https://americanspcc.org/child-abuse-statistics/, accessed 8/15/2020

[17] 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.orghttps://www.ncfrp.org/wp-content/uploads/NCRPCD-Docs/CAN_Guidance.pdf, accessed 8/13/2020

[18] 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.orghttps://www.ncfrp.org/wp-content/uploads/NCRPCD-Docs/CAN_Guidance.pdf, accessed 8/13/2020

[19] 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.orghttps://www.ncfrp.org/wp-content/uploads/NCRPCD-Docs/CAN_Guidance.pdf, accessed 8/13/2020

[20] Ibid.

[21] 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.orghttps://www.ncfrp.org/wp-content/uploads/NCRPCD-Docs/CAN_Guidance.pdf, accessed 8/13/2020

[22] Ibid.

[23] 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.orghttps://www.ncfrp.org/wp-content/uploads/NCRPCD-Docs/CAN_Guidance.pdf, accessed 8/13/2020

[24] Ibid.

[25] 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.orghttps://www.ncfrp.org/wp-content/uploads/NCRPCD-Docs/CAN_Guidance.pdf, accessed 8/13/2020

[26] Ibid.

[27] Ibid.

[28] Ibid.

[29] Keeping Kids Alive: A Report on the Status of Child Death Review in the United States 2017, https://www.ncfrp.org/wp-content/uploads/NCRPCD-Docs/CDRinUS_2017.pdf, accessed 8/13/2020

[30] Keeping Kids Alive: A Report on the Status of Child Death Review in the United States 2017, https://www.ncfrp.org/wp-content/uploads/NCRPCD-Docs/CDRinUS_2017.pdf, accessed 8/13/2020

 

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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.

Blessings,

Jo Calk