Article Text

Role of a child death review team in a small rural county in California
  1. Nancy Keleher,
  2. Dawn N Arledge
  1. Humboldt County Department of Health and Human Services, Public Health Branch, Eureka, California, USA
  1. Correspondence to Nancy Keleher, Humboldt County Department of Health and Human Services, Public Health Branch, 908 7th Street, Eureka, CA 95501, USA; nkeleher{at}


Humboldt County is one of California's most rural counties. Located in far Northern California, it is 6–7 h by car from the nearest major urban areas of San Francisco and Sacramento. In landmass it is one of the largest of the California counties, about the size of Rhode Island. In 1991, the Humboldt County Public Health Branch began a Fetal Infant Mortality Review programme. Because of the county's small size, the Fetal Infant Mortality Review process was combined with the review of child deaths through age 17. Responding to a high proportion of cases of child deaths due to unintentional injury, the team developed a workgroup to explore injury prevention strategies. Funding was identified to hire a coordinator who formed a Childhood Injury Prevention Program and developed a strategic plan. The plan prioritised both motor vehicle/traffic safety related injuries and general childhood injury. Funding was obtained for child passenger safety and youth safe driving programmes. The Childhood Injury Prevention Program also collaboratively addressed other injury prevention areas, including water safety. As a small, rural county in California, committed safety advocates from multiple agencies were able to utilise the child death review process to guide injury prevention efforts. Case reviews provided the motivation and quantitative and qualitative data to design programmes and implement interventions that addressed specific unintentional injuries causing child deaths and injuries in Humboldt County.

  • Adolescent
  • child
  • child death review
  • public health
  • rural

Statistics from

Background and history of team development

Humboldt County is one of California's most rural counties. Located in far northern California, it is 7 h by car to the nearest major urban areas, San Francisco and Sacramento (figure 1). The County encompasses 2.3 million acres, 80% of which is forestlands, protected redwoods, and recreation areas. It is bound on three sides by similar rural counties and on the west by the Pacific Ocean. In landmass it is one of the State's largest counties, about the size of Rhode Island.1 Humboldt County is small in population and ranks 35th of 58 counties in the State. The California Department of Finance estimated the 2009 population at 132 713 with 54% of residents living in outlying, unincorporated areas (State of California, Department of Finance, E-4 Population Estimates for Cities, Counties and the State, 2001–2010, with 2000 Benchmark, Sacramento, California, May 2010).

Figure 1

Map, State of California - Humboldt County highlighted, 2010.

In 1991 Humboldt County became one of 11 counties in California to establish a Fetal Infant Mortality Review (FIMR) programme. Because of the county's small size, the Public Health Branch chose to combine the FIMR process with the review of child deaths through age 17, creating a multi-agency FIMR and child death review (CDR) team. In some smaller areas the CDR process is facilitated by law enforcement agencies where prevention may not always be a primary focus. The combined FIMR/CDR team located in the Humboldt County Public Health Branch allowed for increased community representation with an emphasis on prevention based strategies.

The primary objectives of the FIMR/CDR team are: to maintain data and analyse trends in fetal, infant, and child deaths; to facilitate prompt, coordinated, inter-agency, multidisciplinary response to child death; to make recommendations for interventions at all levels of the spectrum of prevention2; to increase public awareness of preventable measures regarding childhood deaths; and to submit annual reports on team findings.

Formal team protocol was developed in 1992 and is revised as needed. Team membership is closed and includes professional representatives from the following disciplines and agencies: Coroner, Law Enforcement, District Attorney's Office, Child Welfare Services, Medical Providers, Mental Health Branch, Drug & Alcohol Services, Probation Department, Schools, Emergency Medical Services, Indian Child Welfare, and community based children and family agencies. The role of members is specifically outlined in the protocol. Other professional guests are invited on an individual basis if they have direct case specific information or particular subject expertise. No guest or member is permitted to participate if there is a personal or non-professional connection to the case being reviewed. While FIMR and other monies cover a portion of the team coordinator position, no other funding sustains the team. Member participation is voluntary with the support of their agency. The team meets monthly for 2 h and reviews two to four cases each time.

Injury prevention and the role of the CDR team process

One of the major initiatives emerging from this joint review process was a comprehensive response to the high proportion of deaths due to unintentional injuries. In fact, unintentional injuries are the leading cause of child death in Humboldt County. From 1991to 1999, 157 children, youth, and young adults ages 0–24 died and 1578 were hospitalised as a result of unintentional injuries and intentional firearm injures (Humboldt County Childhood Injury Prevention Strategic Plan, September 2002). Unintentional injuries accounted for 71% of all injury deaths and 80% of injury hospitalisations among 0–24 year olds. For the years 1995–1997, Humboldt County ranked 46th worse out of California's 58 counties in unintentional injuries to 0–24 year olds.3

The FIMR/CDR team played a critical role in the surveillance and identification of common risk factors contributing to unintentional injury deaths. As a direct result of team efforts, public health professionals were able to design injury prevention interventions and programmes to address the leading causes of unintentional injury for young people in Humboldt County. The qualitative information gathered by the team enriched the analysis of common risk factors beyond what could be gleaned from quantitative sources. Small numbers and unstable rates have always posed a challenge to understanding fully the impact of childhood injury and death, and case reviews provided an institutionalised method of gathering additional data on all child deaths that occurred in the county. The FIMR/CDR team also created a linked, coordinated network of stakeholder agencies and organisations devoted to preventing injury to young people in the county.

By 1995, the FIMR/CDR team had documented unintentional injury as the leading cause of deaths for children age 1–17 (Humboldt County Fetal Infant Mortality and Child Death Review Annual Report, April 1995). During 1993–1994, 51% of child deaths were from unintentional injuries, with 46% of these deaths from motor vehicle crashes. The report recommended a focus on seat belt and car seat safety. This trend continued, and a review of the FIMR/CDR database from 1991 to 2009 shows that in 1997, 21 out of 23 children age 1–17 died from intentional and unintentional injury causes. That year this small county lost two children from homicide and two from suicide, while 17 children were killed from unintentional injuries, including: a 2-year-old who died when a cement mixer she was playing on fell over and crushed her; a 12-year-old who died from hanging when he slipped and fell while climbing a tree; and the deaths of two young girls from a sand cave collapse. Four other children died from drowning, and six cases involved motor vehicle crashes, including: the death of a child who was in the back of a truck that rolled down a hill and off an embankment; a child who was in a booster seat that was incorrectly installed; and two children who died in separate crashes who were in child safety seats that were not attached to the vehicles.

Details revealed during reviews motivate individuals in a way that data and research can not. The use of the sentinel case review process is a powerful tool for understanding complex situations related to child death and is an important aspect of a full child health monitoring and response system. By examining a story of real life and death, the process reveals graphic situations that are a call to action. For example, it was the case of a 1-year-old child who was killed in a motor vehicle crash that was actually responsible for the original team recommendation to develop an unintentional childhood injury subcommittee. Secured in a car seat, the seat was not attached to the homemade bench where it had been placed. The other family members escaped with minor injuries (Humboldt County FIMR/CDR Team Minutes, 4 February 1998).

Shortly after this review, the team developed a childhood unintentional injury prevention subcommittee. A collaborative of law enforcement and health and human service providers were identified that were committed to reducing the rate of unintentional injuries among children. With support from the team and the newly formed subcommittee, funding was obtained in 2001 to hire a coordinator to develop the Public Health Branch's Childhood Injury Prevention Program (CIPP).

The programme's immediate goal was to develop a strategic plan, and staff utilised the four components of the public health approach to address the issue of unintentional injury among youth: surveillance, risk factor identification, intervention/evaluation, and implementation. The programme established a multi-agency coalition, compiled local data on injuries and deaths from ages 0–24, conducted a community assessment, reviewed FIMR/CDR team findings, and researched effective interventions. During the community assessment, a number of issues emerged as common to childhood injuries: (1) a lack of education/knowledge about, access to, and appropriate use of safety equipment; (2) a lack of adult supervision/neglect; and (3) alcohol and other drug use by parents/caregivers (Humboldt County Childhood Injury Prevention Strategic Plan, September 2002).

These themes had also surfaced during the case review process and reinforced the importance of addressing contributing risk factors when developing interventions. Based on the CIPP's review of effective practices, recommendations for prevention activities were developed and incorporated into the plan. Using prioritisation criteria, the plan was divided into two parts—motor vehicle/traffic safety related injuries, and general childhood injury. The top three priority motor vehicle/traffic safety areas were: child passenger safety; driving under the influence; and youth/young adult driving and passenger safety. Drowning was identified as the top general childhood injury problem area.

Child passenger safety

Having identified child passenger safety as the top priority, the Public Health Branch applied for and received grant funding from the State traffic safety agency to begin a Child Passenger Safety programme. The relationship between the CDR team process and injury prevention activities in this small rural county continued to be critical. Team recommendations provided the foundation for the development of the programme. Case reviews of unrestrained children who died in crashes or were ejected for lack of restraints, incorrect seats for the age of the child, and little use of booster seats underscored the need for parent education, distribution of child safety seats, and community-wide education regarding child passenger safety laws. Together with the effective interventions cited in the strategic plan, including those from the Task Force on Community Preventive Services,4 the programme identified three key goals: (1) to provide parent education on the proper use of child safety seats; (2) to distribute low cost child safety seats to community members; and (3) to support community-wide education and enforcement around the proper use of child safety seats.

The programme responded by creating a multi-agency Child Passenger Safety Coalition, designing a child safety seat parent education and distribution programme, training over 100 individuals to become child passenger safety technicians, and conducting regular ‘inspection station’ events throughout the community to ensure proper installation of child safety seats.

As of 2006 outside funding had ended, but based on the continuing review of child deaths, the Public Health Branch recognised child passenger safety as an ongoing injury prevention priority and identified funding within the Branch to maintain the programme.

Youth driving safety

In 2005, the Public Health Branch began work on another top priority identified by the Strategic Plan—youth driving safety. Although teen drivers and occupants were disproportionately involved in preventable car crashes, no ongoing resources existed within the Public Health Branch to address the issue. Drivers aged 16–19 made up 4% of licensed drivers in Humboldt County, yet they were involved in >10% of collisions that occurred between 2000 and 2004 (California Department of Motor Vehicles, 2005 and Statewide Integrated Traffic Records System, 2005). In 2006, grant funding from the State traffic safety agency supported the development of a youth driving safety programme. Again, the combination of data provided from the CDRs and the literature review on effective injury prevention interventions guided the design of the programme. This led to the development of the following key programme goals: (1) to conduct community-wide education for teens and parents focused on causal factors for local crashes involving young drivers; (2) to work closely with law enforcement on community-wide education; (3) to conduct regular seat belt use surveys at local high schools; and (4) to develop high school appropriate curriculum on the importance of seat belt use and other safe driving habits.

In 2009 the Youth Driving Safety Program received an Award of Excellence from the California Office of Traffic Safety. FIMR/CDR team recommendations played a critical role in the development of the programme, influenced the building of the collaborative, and enhanced the success of the programme.

Water safety

Qualitative team data proved vital for the development of other effective injury prevention activities, including water safety. To address this issue, the top non-motor vehicle related injury area identified by the Strategic Plan, CIPP Coalition partners acted upon team recommendations to create a life jacket loan programme (County of Humboldt, FIMR/CDR Team Recommendations Report, 2005–2006). These efforts prompted community support for a water safety coalition that has conducted community education and awareness activities and created a series of water safety public service announcements. The life jacket loan programme has expanded to six sites near the many rivers and the ocean, where families can check out life jackets.


Though local numbers are small and require cautious interpretation, Humboldt County's death rate due to unintentional injury has declined since the start of the injury prevention programme in 2002. Between 2002–2004 and 2003–2005, the death rate fell from above 30.0 per 100 000 children and youth, ages 0–24, to just above 15.0 (University of California San Francisco Family Health Outcomes Project Data Title V Indicator Template 2002–2005).

According to data reported by the University of California San Francisco's Family Health Outcomes Project, Humboldt County's rate of non-fatal injury hospitalisations for ages 15–24 showed a statistically significant improvement between 1995–1997 and 2004–2006. Specifically for motor vehicle crashes, the rate of non-fatal injuries fell significantly (UCSF, Health Status Indicators, 2009). We cannot attribute these documented improvements directly to the CDR process alone, but in a small rural county like Humboldt where the CDR is so integrated into the community and county public health branch, it is likely that these efforts played a critical role in our successes.


The connection between FIMR/CDR team findings and resulting actions taken by the Public Health Branch demonstrate the potential impact of team reviews on injury prevention activities for small, rural counties. Conducting multi-agency reviews of every death involving a child age 17 or younger is a valuable practice for public health programmes of any size. Since the early 1990s, the Humboldt County FIMR/CDR team has proven to be a powerful tool in the prioritisation and development of injury prevention programmes in the county. Using qualitative information from case reviews, small numbers and unstable rates were never barriers to proceeding with injury prevention efforts. The review process has played a critical role in understanding child deaths and allowed for increased knowledge of risk factors. This information has enabled the team and injury prevention coalition members to design and implement specific, localised interventions more effectively.

Much of the success of the CDR process lies in the implementation of recommendations, a community-wide responsibility. It requires the ongoing commitment of multiple agencies and organisations, and the continuing cycle of reviews has firmly engaged community members and human service providers. These relationships have strengthened both the review process and the resulting collaboratively developed programmes, and have enabled injury prevention programmes and activities to continue, especially during challenging economic times.

What is already known on this subject

  • Child Death Review Teams may offer a more accurate surveillance system of child abuse and neglect, especially when combined with existing CAN reporting systems.

  • Child Death Review Teams yield valuable data for recommendations on preventable deaths to be addressed within local communities.

What this study adds

  • The Child Death Review Team process enables small rural communities to develop interagency partnerships and engage in long-term solutions to address infant, child and adolescent causes of death.

  • Child Death Review Team findings can provide rich qualitative data and the motivation needed to engage a rural community in the development of injury prevention programs.


View Abstract


  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

Request permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.