Our Child Fatality Review (CFR) panel looks at cases of child death that occurred in Kitsap or were Kitsap County residents. This includes infant, child, and adolescent deaths caused by suicide, homicide, sudden unexpected infant death (SUID), unintentional overdose, motor vehicle collisions, falls, fires, drowning, unintentional firearm related injuries, and other means of injury.

Purpose & Process

Purpose Statement

Our panel commits to fostering a multidisciplinary practice to improve collective understanding on the circumstances involved in childhood fatalities, and to catalyze meaningful action that empowers safer, healthier communities, families, and children.

The CFR Process

Child Fatality Review includes three main steps: case identification, review, and prevention.

Identification

We work with the Kitsap County Medical Examiner to identify recent cases that meet our fatality review criteria.

Review

Health District employees obtain relevant medical, legal, and social service records for each case. This information is used to create case summaries that are used in the review. These case summaries do not contain identifiable information.

Fatality Review panel members meet quarterly to discuss cases and identify risk and protective factors. These factors are used to improve prevention efforts.

Prevention

After every CFR, Health District employees summarize case findings in a report available to the public. Case data is entered into the National Fatality Review-Case Reporting System. These reports allow the CFR panel, local community members, and national agencies to develop new strategies to prevent child death and injury.

History

Child Fatality Review panels were created in the United States during the 1970’s to prevent child abuse and neglect. Now, panels look at a wide variety of causes of death. Our health district has a near 30-year history of hosting CFR panels.

Timeline:

• 1998: We establish the first CFR.

• 2015: We lose funding and make the difficult decision to suspend CFR.

• 2022: Washington state legislature establishes Foundational Public Health Services (FPHS) funding.

• 2023: We re-establish CFR panels.

• Present: We meet quarterly to discuss cases of child death.

CFR Panel

Our panel is a group of diverse and dedicated experts from fire departments, mental health organizations, youth services, local government, hospitals, and other Kitsap-based agencies. Each panel member provides information and records, explains procedure, and identifies ways to prevent death and injury. The panel honors all confidentiality agreements.

Panel Well- Being

Having an invested group of representatives is crucial in this process, but we know reviewing child death can take a toll on health and well-being. We prioritize supporting our CFR team by using strategies developed by the National Center for Fatality Review & Prevention.

Reports & Recommendations

2023

Accident report & recommendations

Overdose report & recommendations

Suicide report & recommendations

Additional Resources

National Center for Fatality Review and Prevention provides technical support and data center serving Child Fatality Review (CFR) and Fetal and Infant Mortality Review (FIMR) programs throughout the United States.

Child Death Review (CDR) & Prevention supports local health jurisdictions with Child Fatality Review programs across the state.

Child Fatality Review (CFR) in Washington State is authorized by a state law in Washington under RCW 70.05.170.

Questions?

To learn more about the CFR process or injury and death prevention, email cdp@kitsappublichealth.org