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Analysis of paediatric drowning deaths in Washington State using the child death review (CDR) for surveillance: what CDR does and does not tell us about lethal drowning injury
  1. Linda Quan1,4,
  2. Diane Pilkey2,
  3. Anthony Gomez3,
  4. Elizabeth Bennett4
  1. 1University of Washington School of Medicine, Seattle, USA
  2. 2Washington State Department of Health, Olympia, WA USA
  3. 3Public Health Seattle & King County, Seattle, WA USA
  4. 4Seattle Children's Hospital, Seattle, WA USA
  1. Correspondence to Dr Linda Quan, Seattle Children's Hospital, 4800 Sand Point Way NE, B-5520 Seattle, WA 98105, Linda, USA; linda.quan{at}


Background Drowning is second cause of paediatric injury death in Washington State. Child death review (CDR) data provide the unique opportunity to identify regional risk factors and opportunities for drowning prevention.

Methods CDR teams' data for drowning deaths of children <18 years between 1999 and 2003 were analysed for victim and event characteristics, and existing prevention/protective factors. A working group made data driven recommendations. Subsequent interventions were noted.

Results Drowning death rates were significantly higher among Asian Pacific Islander children (3.3 per 100 000). Disproportionately, 32% of deaths involved families with prior child protective services (CPS) referrals. Most deaths (73%) occurred in open water; the proportion in open water increased from 42% of <5-year-olds, 83% of 5–9-year-olds, to 90% of 10–17-year-olds. Thirty per cent drowned at parks; 29% drowned in residential settings. Pre-drowning activity for 42% was swimming or playing in the water. Alcohol and drug use were low. Neglect/poor supervision was considered a factor in 68% (21/31) of the deaths of children <5 years of age. State CDR recommendations led to the development of a drowning prevention campaign targeted to an Asian American community, intra-agency changes resulting in reinstatement of lifeguard staffing and addition of lifejacket loaner programmes, collaboration with state commissions to enforce a state pool fencing ordinance, and model legislation prohibiting swimming in dangerous waterways.

Conclusion CDR data collection and review process was an effective surveillance tool. It identified specific regional high risk groups and sites for drowning prevention and led to recommendations and implementation of effective local and state injury prevention interventions.

  • Drowning
  • surveillance

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Drowning is the second major cause of unintentional injury death in children aged 1–17 years in the USA and Washington State.1 Although decreasing significantly since 1990, in 2003, overall Washington State drowning death rates for children ages 0–19 remained higher than national rates, 1.6 versus 1.4 per 100 000.1 2 This prompted Washington State's Child Death Review State Advisory Committee to establish a Drowning Workgroup to review its drowning deaths to identify drowning prevention opportunities.3

Child death review (CDR) is a process by which local communities collect and report detailed uniform information about the unexpected death of any child. For each child's death they review reports from multiple agencies, including police, prehospital care, and child protective services; promote communication between local health jurisdictions, law enforcement, social services, and medical providers; and develop prevention strategies.4–6 With small numbers of local cases, state teams often report their findings and recommendations on the internet.6 Few peer reviewed CDR reports have focused on a specific injury or evaluated outcomes.5

Washington State's CDR Drowning Workgroup, which included all authors, conducted an in-depth review of 5 years of paediatric drowning deaths. Our goal was to describe use of this CDR drowning dataset as a surveillance tool, identifying specific drowning prevention needs and providing data driven prevention activities both locally and state-wide.


Research design

This was a retrospective case series.

Case selection

Cases comprised children <18 years of age who resided in Washington State and died between 1 January 1999 and 31 December 2003 due to intentional and unintentional drowning as determined by the medical examiner or coroner. We excluded drownings due to motor vehicle, aeroplane crashes, and electrocution.


Washington State forms the northwest corner of the USA; its western border is the Pacific Ocean with >3000 miles of coastline; its southern border is the Columbia River; it has >120 rivers, 29 major lakes (1000–80 000 acres), and countless numbers of low country and alpine lakes.

Data sources

Between 1999 and 2003, child death review teams (CDRTs) existed in 38 of 39 counties in Washington State. Teams reviewed deaths within a year of the death, using local information from medical examiners/coroners, death scene investigations, medical records, law enforcement, emergency medical services, public health records, medical records, social services, and other sources.


Teams used a standard data form developed by the Washington State Department of Health (DOH) and the Department of Social and Health Services. It included information about the child, including family and medical history, characteristics of the drowning event, who was supervising, substance use associated with the drowning victim or supervisor, prior involvement of child protective services (CPS) with the family, and specific drowning prevention questions, including the presence of a locking gate around pools and ponds or of a lifeguard, and whether the child was supervised, wore a lifejacket or had taken swimming lessons.6 Teams also determined whether a death was preventable ‘if a reasonable medical, educational, social, legal or psychological intervention could have prevented this death from occurring’. ‘A reasonable intervention is one that would have been possible given the known conditions or circumstances and the resources available.’ Neglect was defined as actions or omissions resulting in injury to or creating a substantial risk to the physical and/or mental development of a child.

Teams completed reviews and submitted data electronically to Washington State DOH.

To estimate the completeness of the CDR data, for the same period and age group, we counted all drowning deaths in all counties using the International Classification of Diseases, 10th revision (ICD-10) codes W65-W74, V90-92, X71, X92,Y21 in the death certificate data, Washington State DOH, Center for Health Statistics. Drowning rates were calculated for gender, age group, and race by dividing the number of drowning deaths from the death certificates by state population estimates for those specific groups. Frequencies and rates were generated using Stata statistical software.7 Confidence intervals (CIs) for rates were estimated using exact Poisson methods.8–10 To compare rates of different groups, exact Poisson regression based on mid p values was used with significance at p<0.05. Trends were analysed using Joinpoint 3.0.


Death certificate data

Death certificate data identified 127 children aged 0–17 years with drowning as the primary cause of death for the period 1999–2003. Drowning rates were highest in those aged 15–17 and 0–4 years (2.6 and 2.5 per 100 000, respectively). Male drowning rates were three times the female rates (2.5 vs 0.8 per 100 000) and represented 76% of the deaths (table 1).

Table 1

Demographic characteristics of drowning victims based on death certificate data, ages 0–17 years, 1999–2003 (n=127)

Most (67%) child drowning deaths involved Non-Hispanic whites. However, whites (1.5 per 100 000, 95% CI 1.2 to 1.9) and Hispanics (1.4 per 100 000, 95% CI 0.7 to 2.4) had the lowest death rates. Drowning rates were significantly higher among Asian-Pacific Islander children (3.3 per 100 000, 95% CI 1.9 to 5.3), who comprised 13% of the deaths but only 7% of the state population of children ages 0–17 (table 1).

Almost all death certificate deaths (n=122, 96%) were determined to be unintentional by the medical examiner or coroner; two were intentional (one suicide, one homicide); three were of undetermined manner. No drowning deaths occurred in the county that lacked a CDRT.

Highlights from the CDR data

Of the 127 drowning deaths, 73% (93) were reviewed by Washington CDRTs. Reviewed and non-reviewed deaths (n=34) were similar in age, gender, and race. Before 2003, 81–90% of all drowning deaths were reviewed. In 2003, only 43% of the deaths were reviewed. In July 2003, several teams stopped meeting as state funding of CDR teams ceased.

Water location

Most drowning deaths (73%) occurred in open waters (table 2). Most bathtub (63%) and pool/hot tub deaths (76%) involved children <5 years. The proportion of drownings in open water increased with age, from 42% of <5-year-olds, 83% of 5–9-year-olds, to 90% of 10–17-year-olds.

Table 2

Characteristic of drowning events, 1999–2003 (n=93)

Place of injury

Twenty-eight children (30%) drowned at a residence. Thirty (32%) drowned in a city, state, or county park (table 2). Data were not routinely collected as to whether the drowning occurred in a designated swim area or when lifeguards were on site.

Pre-drowning activity

While the most common pre-drowning activity was swimming or playing in the water (n=39, 42%), playing near the water led to 23% of the deaths (table 2).

Swimming pool deaths

Most swimming pool, wading pool or hot tub related deaths (14/17, 83%) occurred in private residences. Although the presence of a fence was not a routinely collected variable, at 14 residences, only two had a locked gate but with a gap in the fence that a child could squeeze through. For the remaining pools, two had an unlocked gate, eight had no gate, and for two the presence of a gate or if it was locked was unknown. The three non-residential pool drownings occurred in a lifeguarded public pool, at an unlifeguarded fitness centre, and a city park, where lifeguard presence was unknown. No deaths occurred in apartment or condominium pools.

Known risk factors

Older adolescents

Those aged 15–17 years represented 31% of the cohort. Almost all (28/29, 98%) drowned in open water. Most (62%) were swimming or playing in the water. Only five were boating. Twelve (41%) were with friends at the time of their drowning. Five (17%) tested positive for alcohol or illicit drugs.

Alcohol or drugs

Only 10% (9/93) of drownings involved alcohol and/or illicit drugs; most (7/9) were adolescents. Two children <5 years were supervised by parent/care provider who was noted to be impaired by alcohol/drugs at the time of the drowning.

Chronic health conditions

In the 12% of children with chronic disorders, seizure disorders (n=5) were the most common; others had developmental delay, attention deficit disorder, autism or diabetes.


Of the 38 who were not in the care of an adult, three were unsupervised; seven children aged <12 years were with other children. Seventeen were 13–17-year-olds with siblings or peers. For four drownings, a lifeguard was present at a swimming pool (one) and lake parks (three).

CPS history

Nearly one third—30 (32%)—of the children's families had a history of prior referrals to CPS; 25 had had at least one CPS investigation.

Preventive factors

Three children were wearing a lifejacket when they drowned (one wore a lifejacket that did not fit; two were in rivers). Only one of the seven children in boats wore a lifejacket. Six children had previous swimming lessons; only 28% (26/93) were reported to be able to swim.

Team assessment

Local CDR teams concluded that 85% of the deaths were preventable. Teams found no intentional or indeterminate deaths, but cited neglect as a factor in 68% (21/31) of children <5 years. Of these, 10 families had at least one CPS referral in the past. The teams noted these deaths were generally isolated acts of neglect due to inadequate supervision rather than a pattern of neglect.

Impact of CDR reviews

Based on these findings, the Drowning Workgroup made five recommendations to guide drowning prevention across the state3 (box 1).

Box 1

Box 1 Child death review Drowning Workgroup: drowning prevention recommendations

  1. Increase lifejacket use and supervision of children and adolescents in or near the water.

  2. Create physically safe water environments.

  3. Encourage policies and regulations that emphasise water safety.

  4. Raise community and personal awareness of child and teen drowning risk factors and prevention/safety strategies.

  5. Support standardised drowning death investigation procedures and improve data collection efforts.

Each recommendation included specific strategies to guide CDR teams, such as life jacket loan programmes to increase lifejacket use or incorporating open water risk into swimming instruction at pools to raise risk awareness. Importantly, the list represented consensus and priorities among state drowning prevention leaders.

CDR drowning reviews led to local strategies. High drowning rates in Asian American children prompted a drowning prevention campaign in one region's large Vietnamese American community. Reviewing several years of data, one CDRT recognised an annual swimming related drowning death risk at a specific body of water. This led to legislation in 1999 closing that body of water to swimming, set a state-wide precedent for municipal control of recreational water use, and resulted in zero deaths in those waters subsequently (figure 1).

Figure 1

Example of local child death review (CDR) action: process to results.

CDR analysis also led to statewide interventions. It was critical in showing the legislature and governor that significant drowning events occurred at times and places at parks that had previously had lifeguard services before budget cuts. In showing the overrepresentation of various minority groups it established the lack of lifeguard services as an important health disparities issue and the need for a more comprehensive prevention effort on the part of the state. Specifically, it led to adding a risk manager position to the Washington State Parks Agency, and installation of a lifejacket loaner programme and reinstatement of lifeguards at some parks (figure 2). In addition, CDR specific data on inadequate fencing drove collaboration with Washington State's Building Code Council to regulate, educate, and enforce housing code compliance and coordination functions.

Figure 2

Examples of state child death review (CDR) actions: process to results.


The CDR process was a valuable surveillance tool for drowning injury. Analysis of 5 years of CDR data identified the need to: (1) target two specific risk groups among Washington State children—racial/ethnic minorities, specifically Asian/Pacific Islander Americans, and children whose families had prior involvement with CPS; (2) focus on open water settings and activities; and (3) collaborate with city, county, and state parks as key agencies. Moreover, CDR data provided evidence which contributed to subsequent practice or policy changes in several state and local agencies that oversee recreational water use and sites, and may have had an effect on drowning deaths. Furthermore, data suggest these actions may have saved lives.


One limitation is that not all drownings were reviewed. However, the majority was reviewed, having characteristics similar to unreviewed drownings. Small numbers often hampered statistical significance. However, detailed data on individual circumstances had qualitative value, especially when coupled with local knowledge. Missing data primarily occurred in variables assessing protective factors such as the status of pool fencing, swimming ability, and use of designated swim areas in open water. Improved data collection might improve with education addressing these newer concepts with CDRTs and the agencies that collect the data. Improved data collection is needed to develop and monitor prevention programmes.

Although supervision was considered negligent in so many deaths, CDR review provided little insight into assessing supervision. Subsequently, key domains of supervision have been delineated.11 CDRT could better evaluate supervision by adding data variables that assess the caretaker's attentiveness, alertness, and proximity to the child. However, CDR assessment of parental drug and alcohol use was an important step to identify and codify key components of supervision.

Major strengths

This CDR review demonstrated CDRT's unique access to and ability to integrate key data across the entire Haddon matrix. It provided critical data about the host, the injury event, and the environment critical to identifying, developing, and monitoring prevention efforts. Revised in 2010, CDR case reports collect injury specific data.12 Other more commonly used data sources for surveillance do not meet the definition of “Public Health Surveillance as the ongoing, systematic collection, analysis, and interpretation of data (eg, regarding agent/hazard, risk factor, exposure, health event) essential to the planning, implementation, and evaluation of public health practice, closely integrated with the timely dissemination of these data to those responsible for prevention and control.”13 Death certificate data, the most commonly used surveillance tool, provides only basic demographic data which become available 2 or more years after the death. Newspaper clipping data are always incomplete14 (table 3).

Table 3

Comparison of drowning prevention variables among different datasets used for surveillance

Host factors

Racial/ethnic disparities

Other studies have identified increased drowning risk among non-white US children.15 16 Between 1995 and 2003, Asian Pacific Islander children and especially Asian males >5 years of age had higher unintentional drowning rates than whites in the USA.1 However, in another study, Asian American children had the lowest mortality rates for all injuries, including drowning.17 The drowning experience of Asian American children in this state identifies the need for ongoing state surveillance. In Canada drowning risks may be explained by significant differences in water use among new immigrants.18 CDR teams could identify ethnicities, assess the immigrant status of families, and determine if ethnicity is a proxy for new immigrant status. This level of specificity is needed to develop culturally and linguistically appropriate prevention interventions.19

CPS data

Although this study could not calculate drowning risk among families with CPS involvement, this group appeared overrepresented. While we do not have data on the percentage of Washington State children whose families ever had a referral to the CPS, in 2003 the CPS reported that they had accepted referrals for 2% of the population of children (20 per 1000).20 Although this is the first description of this association with drowning injury, concomitant Washington State CDR reviews showed similar or even higher proportions of CPS referrals in other injury deaths.21 22 As previously reported, these families represent a high risk group for targeted injury prevention interventions.23

Pre-existing conditions

Among injury surveillance systems, only CDRTs can identify past history and pre-existing disease. As a surveillance tool for known risk factors, CDR analysis showed the prevalence of pre-existing seizures (6%) remains unchanged from older reports in this region.20 Increasingly, larger numbers of children with disabilities and chronic diseases comprise the paediatric population and are a group for whom injury risk needs to be identified.

Event factors

Pre-drowning activities

This CDR analysis showed the need for a state-wide focus on non-boating related open water drowning prevention for children. It was able to accomplish this by having access to descriptive data from the scene unavailable in death certificate data. Unlike the young child, school aged children and adolescents meant to be in the water, swimming or wading. Prevention tactics are needed to address these activities. The relatively low rate of alcohol use (7/29, 24%), similar to previously reported rates in 15–19-year-olds in Western Washington, suggests that drowning prevention efforts for teens should not focus solely on decreasing alcohol use.23

Environmental factors

Identification of risk sites

Most drowning deaths occurred in open waters. Even among those children aged <5 years old who typically drown in swimming pools in other states, as many drowned in open water as in swimming pools in this state. Case death rates are highest for open water settings compared to swimming pool or bathtub settings in this region.24

Importantly, by aggregating teams' data, CDR analysis identified specific open water risk sites across the state. More children died at park settings than swimming pools. The high proportion in park settings may reflect greater use of these sites for family water recreation, especially by low income groups, including racial and ethnic minorities who have greater drowning risk. This identified the need to make these sites safe for wading and swimming. CDR surveillance added to a concomitant review of drownings at Washington State's parks that recommended changes to the infrastructure and culture of prevention/safety within the state's park agency to environmental changes at park beaches, and reinstating lifeguards at heavily used parks25 (figure 2). Representatives from agencies where drownings occur would be key to include in CDRTs to help start and monitor drowning prevention initiatives.

Pool drowning deaths—although a relatively small burden of injury, and almost exclusively involving young children in this state—are preventable with appropriate fencing.26 Recently, Washington State's Building Code Council legislated a statewide requirement for isolation (four sided) fencing of new residential pools and spas, with options of alarms and various covers. This CDR evaluation identified drownings in residential pools that had fencing but which was inadequate or had non-working gates. This highlights the need for education, enforcement, applying laws to existing pools and not just new pools, and further work with building code programmes.

Future directions

Presently, with budget cuts, only 18 (46%) Washington State counties fund local CDRTs. In counties with small numbers and types of cases, it may take years to fully depict and comprehend local drowning risks and patterns. Unfortunately, many CDRTs terminated when just beginning to assemble enough local data to take those next steps towards policy, system, environmental or organisational changes. The diminished number of reviews and reduction in data significance has and will impact what could be translated to prevention of future injury and deaths throughout the state. State and county systems will be left to respond and react to individual cases or clusters of cases instead of better and more regional data. Funding CDRTs as a statewide surveillance tool protects a large population since most of the drowning interventions that have been developed, especially for open water, affect adults as well as children.


In conclusion, CDR data and review process was an effective surveillance tool, providing identification and insight into regional risk factors for drowning and opportunities for prevention. Its unique database led to effective local and state injury prevention strategies. The changing demographics of American society will require greater attention to new groups and their risk for injury, such as diverse communities and children with pre-existing conditions. To improve drowning injury prevention and evaluate its effectiveness, continued and enhanced CDR surveillance is needed. CDR programmes are key to comprehensive and effective injury programmes at local and state levels.

What is already known on this subject

  • Child death review (CDR) data provide detailed, integrated data from multiple sources.

  • CDR data have the potential to identify needed prevention efforts.

What this study adds

  • CDR evaluation has a unique role in identifying new risk groups for drowning in this state: Asian American children and families with prior CPS referrals.

  • CDR evaluation identified specific risk sites for drowning death: open water, specifically city, county, or state parks.

  • CDR evidence based recommendations led to prevention efforts at the community, agency, and legislative/policy changes.


We thank the CDR teams of Washington State for their work and dedication to the CDR process and reviews.



  • All authors have been involved with the project design, implementation, review and writing of the paper.

  • Competing interests None.

  • Ethics approval This study was conducted with the approval of the Seattle Children's Hospital Institutional Review Board.

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