Interview With the N.C. Child Fatality Review Team

When a child dies in North Carolina, and that child's family has been involved with a county department of social services within the last twelve months, and there is a suspicion that abuse or neglect was a factor in the death, the North Carolina Division of Social Services State Child Fatality Review Team reviews the case.

The purpose of its review is not to affix blame for the death, but to improve our understanding of why these fatalities occur and to develop recommendations for preventing them in the future. In 1999—2000 the State Child Fatality Review Team reviewed 30 deaths in 17 North Carolina counties.

To learn about what this team can tell us about responding to and preventing child deaths, Practice Notes spoke with Sara Anderson Mims, head of the Children's Services Section's Program Review Team, and Debra McHenry, a Program Consultant with responsibility for Fatality Reviews within the N.C. Division of Social Services.

CSPN: What would you like to say to child welfare workers and supervisors about child fatalities?

Mims: A child dying for any reason is a tragedy, but a child dying because of abuse or neglect is even more tragic. Child fatalities are hard to even think about, much less discuss. Yet, we must.

Workers tend to think, "This can't happen to the families that I'm working with." When it does, it's devastating. And the response from the media and the community can sometimes make that even more painful and grief-provoking for the worker, their coworkers, supervisors—all the way up to the director.

It is important, we think, for folks in the field to really think about the fact that this could happen to them, and to do some sort of preparation ahead of time for how they will handle communications issues, help staff with the grief process—all the stuff you can't think about in the moment when it has happened.

CSPN: What should workers keep in mind if a fatality happens in their agency?

Mims: When there's a fatality, DSS must immediately determine whether there are other children in the home. If there aren't, DSS is not involved. If there are, DSS must decide whether those children can remain in the home, whether protective services are needed, or whether they should be removed from the home.

McHenry: Workers and supervisors should understand that assessments after a fatality need to be very broad in scope. To ensure the safety of the surviving siblings we [DSS] must understand how the fatality happened.

As the experts in child abuse and neglect, we must look for those factors which may have contributed to the death and decide if they rise to the level of neglect or abuse. We then must share this information with both the police and the medical examiner so they can make a good decision about the incident.

CSPN: What do you mean by "broad in scope"?

McHenry: In reviews we often find that school, medical, mental health, and substance abuse information is very important. Often social workers don't request this information because it doesn't seem relevant. Yet it is usually essential to developing the total picture of child safety that workers and their supervisors need to make decisions.

Mims: One of the things we find in almost every fatality that we review is that somebody had a piece of information that somebody else needed and didn't tell them. This is true for most ordinary CPS investigations, too.

McHenry: Sometimes DSS doesn't go looking for all the information, and stops short of asking all the questions necessary to ensure the safety of surviving siblings. You must think about how to use your collaterals in an investigation to help you get the whole picture. Help other professionals and the community understand that when it comes to children's safety, confidentiality is secondary.

CSPN: What about talking with the family?

Mims: There is a real difference in how you approach the family. When a child has died, you've got a family in grief over the loss of a child, and the family may also be blamed for that death. Yet you still have to determine the safety issues for the other children in the home.

McHenry: It's really a balancing act. While you feel badly for someone grieving the loss of their child, you still have an obligation to determine safety. It is a very difficult situation. Most of the time you start investigating even before the funeral has taken place.

CSPN: What's the likelihood that the police or others looking into a child death will touch base with DSS while doing their investigations?

McHenry: It's important that DSS, the police, and the medical examiner work together very closely. Too often, I hear from DSS's that they are waiting for the police or the medical examiner to tell them what happened. It is important to remember that DSS has the expertise and the responsibility for determining if there was abuse or neglect involved. Otherwise, how can you make a judgment about the safety of the surviving siblings?

Our reviews show that children are best protected when we combine the unique skill and knowledge of the police, DSS, and the medical examiner. These three professionals should work side by side to determine what happened in a child's death. Each brings part of what is needed to understand the events leading up to the fatality.

We would be glad talk with your county about multi-disciplinary responses to child fatalities. Learning more about the unique expertise and the limitations of each of these professions can facilitate good team work and make North Carolina a safer place for children.

CSPN: How should an agency assess safety of the remaining children when there's been a fatality and Sudden Infant Death Syndrome (SIDS) may have been the cause?

Mims: Layovers, where a parent has an infant in the bed with them and rolls over and the infant is smothered, and SIDS are real complicated issues. There may not be enough evidence for anybody to be charged or enough for the medical examiner to put something on the death certificate indicating abuse and neglect, but DSS needs to have their eyes wide open. They can't just say "Well, the medical examiner said it was SIDS and the police aren't going to charge anybody . . . ." They've got to ask the medical examiner and the police in a very direct way whether they think substance abuse or alcohol was involved and whether the death was in any way suspcious.

McHenry: There's a real misunderstanding sometimes about SIDS. DSS looks at it as some medical reason for a child dying that can be determined, when the reality is that SIDS means that despite the medical examiner's best efforts, they can't tell what killed the baby. A baby could be smothered and you would not necessarily be able to tell. That's where, if there's a good investigation done by the police and DSS has additional information, it might give the medical examiner enough information so they might rule the death something else, or at least undetermined.

CSPN: What have you learned about other risk factors in child fatality cases?

McHenry: Last year, out of 22 child deaths* that we intensively reviewed, 17 had both domestic violence and substance abuse as major issues in those families. One had just domestic violence, and one had just substance abuse. So it appears that when you have substance abuse and real violence in a home, the chances for a child fatality seem to be increased. We can't say that for sure, but that's a real high percentage of deaths having both of those factors in them. Also, most of the deaths we review actually come from neglect. We're pretty good about keeping kids safe when there's abuse. What all this means for practice is that you need to do a comprehensive assessment in all of your CPS investigations. Often times workers—I think because of feeling pressed for time—are just dealing with the issue at hand. So therefore they may not get all the information they need to assess safety for children.

CSPN: If there's been a fatality in their community and your team will be coming to review the case, what can a county DSS do to prepare?

McHenry: We understand that some agencies are apprehensive before a review. The whole review process will be easier if, when you assessed the safety of surviving siblings, you gathered comprehensive information from schools, doctors, and every agency that knew members of this family, including the dead child. If this is not the case, there will be more work leading up to the review as we try to gather any missing information.

As far as the review process itself, we know it will be difficult for you. You'll have to relive an awful situation, and a lot of people will be looking at your work. Please know that we understand how this process may feel to you. As we conduct the review, we must perform a deli cate balancing act that mirrors the one that you must perform after a fatality. To learn what we can to prevent future child deaths, we must conduct a thorough, objective review. Yet at the same time, we care about and are there to support the people most involved with this tragedy.

More Information

If you have questions about child fatalities in North Carolina or about the State Child Fatality Review Team, please contact Sara Anderson Mims, Debra McHenry, or Carlotta Dixon at the N.C. Division of Social Services, Children's Services Section, Program Review Team, 325 N. Salisbury Street, Suite 772, 2407 Mail Service Center, Raleigh, NC, 27699-2407. Tel: 919/733-9461. You can also find the child fatality review protocols and the most recent annual report from the State Child Fatality Review Team by visiting <childrensservices.dhhs.state.nc.us/programreview/fatality_protocol.htm>.

  * Editor's note: Due to when the fatalities occurred, at the time of the interview the NC Child Fatality Review Team had conducted intensive reviews of only 22 of the 30 qualifying child fatalities that occurred last year. All qualifying fatalities are reviewed as soon as possible.