Statement of purpose Child death review (CDR) teams provide insight into why child deaths occur by conducting systematic investigations to identify missed opportunities to prevent each death under review and recommend strategies to prevent future deaths. Investments in the CDR system to date have prioritized building the system and expanding participation. Attention to implementation to identify best processes and practices is now needed.

Methods/Approach We conducted in-depth interviews with 19 CDR team coordinators to understand how their teams are organized, the process for reviewing a death and issuing prevention recommendations, and how the recommendations are used to impact child death in their jurisdictions.

Results Respondents stressed the importance of relationships with their internal and external partner organizations. Strong relationships facilitate data sharing, CDR team participation, and being able to have an impact on the community. Some respondents were challenged to articulate how CDR has impacted child death in their communities. While almost everyone stated that there had been a decline in child deaths over the years, few respondents could quantify how or point to an example where the results of the CDR meetings prevented child injury and rarely reported being engaged in translating the recommendations into action.

Conclusions CDR teams provide a strong foundation for identifying local vulnerabilities for child injury and death, but lack resources to act on recommendations.

Significance New strategies are needed to help bridge the gap between the work of CDR teams and injury prevention policy and practice.