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Child death reviews: a gold mine for injury prevention and control
  1. Chukwudi Onwuachi-Saunders1,
  2. Samuel N Forjuoh2,
  3. Patricia West3,
  4. Cimon Brooks1
  1. 1Delta Consultancy Group, Washington, DC, 901 6th Street, SW, #401, Washington, DC 20024, USA
  2. 2Department of Family Medicine, Texas A&M University System Health Science Center, Scott and White Clinic and Memorial Hospital, Temple, Texas
  3. 3Public Health Consultant, Philadelphia, Pennsylvania
  1. Correspondence and reprint requests to:
 Dr Onwuachi-Saunders 
 (e-mail: cashakir{at}


Objectives—The purpose of this study was to demonstrate how child death review teams can be used to prevent future deaths through retrospective, multiagency case analysis and recommendations for educational programs and policy change.

Methods—A listing of all deaths to persons ages 21 years and younger in Philadelphia that occurred in 1995 was compiled by the Philadelphia Interdisciplinary Youth Fatality Review Team (PIYFRT), a multiagency, multidisciplinary, community based group created in 1993 with the mission to prevent future deaths through review, analysis, and initiation of corrective actions. Data were collected on demographic variables, as well as the circumstantial variables on injuries such as weapon type, alcohol and drug use, and contact with the criminal justice system, among others. Each case was reviewed thoroughly to determine whether or not the death was preventable. Selected injury related death cases were analyzed further by demographic and circumstantial variables.

Results—In 1995, 607 children ages 21 years and younger died in Philadelphia from natural causes (61.6%), unintentional injuries (16.3%), homicide (18.6%), suicide (2.3%), and undetermined causes (1.2%). More than a third (37.2%) of all deaths were considered preventable. Of the injury deaths (n=224), 95% were judged to be preventable. Preventable fire/burn injury deaths (n=29) were associated with lack of a smoke detector, non-supervision of children, and faulty home appliances. Violent deaths were associated with substance abuse, gang involvement, chronic truancy, academic failure, and access to weapons.

Conclusions—Relevant policies for these preventable or intervenable deaths are discussed such as use of non-battery powered smoke detectors.

  • death reviews
  • child death reviews
  • violence

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