TABLE OF CONTENTS

Introduction ● List of Figures, Tables, Maps, and Charts i● Acknowledgements iii● Letter from the Chair iv● Reading This Report vi

Chapter 1: Operations and Activities ● What to Expect in this Chapter 1● Operations 2● Data and Limitations 5● Coverage by Local Child Fatality Review Teams 7● Texas Child Fatality Review at the Community Level 11● Notable Activities and Collaborations in 2007 19

Chapter 2: Recommendations ● What to Expect in this Chapter 23● Recommendations to the Governor and State Legislature 24● Recommendations on Child Protective Services Operations 27● Recommendations to the Department of State Health Services 28

Chapter 3: Data and Analysis ● What to Expect in this Chapter 29● Generalizability of CFRT Data 30● An Overview of Mortality in Texas 32● Understanding Causes of Death 35● Natural Causes of Death 36● Unintentional Injuries 38● Intentional Injuries 41● Firearm Deaths 46

Appendix A: SCFRT Committee Members Appendix B: Active Local Child Fatality Review Teams, 2007 Appendix C: Texas Family Code Appendix D: How to Start a CFRT in Your Community Appendix E: Population by Age, Race/Ethnicity, and Gender Appendix F: Trends in Texas Child Death by Age, Race/Ethnicity, and Gender, 1990 through 2005

Introduction

i

LIST OF FIGURES, TABLES, MAPS, AND CHARTS

List of Figures Figure # Title Page # Figure 1

DSHS Support of CFRT

4

Figure 2 Causes of Mortality Included in the 2005 CFRT Annual Report 35 List of Tables Table # Title Page # Table 1

The Value of Volunteerism

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Table 2 Comparing Reviewed Deaths to All Deaths, All Cause Mortality, 2005 30Table 3 Comparing Reviewed Deaths to All Deaths, Natural Causes of Mortality, 2005 31Table 4 Comparing Reviewed Deaths to All Deaths, Injury Causes of Mortality, 2005 31Table 5 Sex, Race/Ethnicity, and Age of Children who Died of Drowning, 2005 38Table 6 Sex, Race/Ethnicity, and Age of Motor Vehicle Fatalities, 2005 40Table 7 Sex, Race/Ethnicity, and Age of Child Deaths from Homicide, 2005 42Table 8 Sex, Race/Ethnicity, and Age of Child Suicides, 2005 44Table 9 Sex, Race/Ethnicity, and Age of Child Firearm Deaths, 2005 47 List of Maps Map # Title Page # Map 1

Active Child Fatality Review Teams, 2005

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Map 2 Proportion of Death Certificates Reviewed by Team, 2005 9Map 3 Active Child Fatality Review Teams, 2007 10Map 4 Local CFR Teams with CAC Leadership, 2007 11Map 5 Child Mortality Rates by County, 2005 34Map 6 Number of Child Deaths by County, 2005 34

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List of Charts Chart # Title Page # Chart 1

Number and Proportion of Child Deaths Reviewed, 1995 through 2005

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Chart 2 Trends in Child (0 through 17 years of age) Mortality, 1990 through 2005 32Chart 3 Trends in Child (15 through 17 years of age) Mortality, 1990 through 2005 32Chart 4 Infant Mortality Rates by Race/Ethnicity, 2005 33Chart 5 Child (Ages 1 through 17 years) Mortality Rates by Race/Ethnicity and Age, 2005 33Chart 6 Child Deaths by Cause and Age, 2005 35Chart 7 Age at Death among Infants who Died of SIDS, 2005 36Chart 8 SIDS Rates, 1990 through 2005 37Chart 9 Proportion of Cases Where Behavior was Reported, 2005 37Chart 10 Number and Rate of Drowning Deaths, 1990 through 2005 38Chart 11 Number and Rate of Child Motor Vehicle Fatalities, 1999 through 2005 39Chart 12 Classification of Child Motor Vehicle Fatalities, 2005 40Chart 13 Number and Rate of Child Deaths from Homicide, 1999 through 2005 41Chart 14 Location of Child Deaths from Homicide, 2005 42Chart 15 Assailant in Child Deaths from Homicide, 2005 43Chart 16 Suicide Death Rates, 1990 through 2005 43Chart 17 Location of Child Suicides, 2005 44Chart 18 Contextual Factors Surrounding Child Suicide, 1999 through 2005 45Chart 19 Number of Firearm Deaths, 1999 through 2005 46Chart 20 Proportion of Firearm Deaths Attributed to Unintentional Death, Suicide, Homicide, and Unknown Intent, 1999 through 2005 47Chart 21 Owner of Firearm in Firearm Related Deaths, 2005 48

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ACKNOWLEDGEMENTS

The Texas State Child Fatality Review Team (SCFRT) Committee would like to gratefully acknowledge the following for their dedicated service to the children of Texas and contributions to the SCFRT. These individuals are applauded for their service and wished the best in future endeavors.

Sandi Wiggins, MPA, Denton County Public Health Department, who has served as both the SIDS Family Service Provider and the Public Health Professional on the SCFRT.

Wanda Pena, LMSW, Texas Department of Family and Protective Services (DFPS), who served both as past Child Fatality Review Team Coordinator and as designated staff representing DFPS on the SCFRT.

A special debt of gratitude is due to Denise Oncken, JD, Harris County District Attorney’s Office, for her two years of service as Chair of the State Child Fatality Review Team Committee. This report was written and edited by Department of State Health Services (DSHS) staff that includes SCFRT member Fouad Berrahou, PhD, State Title V Director, and staff from Office of Title V and Family Health, which includes Brian Castrucci, MA, Director, Family Health Research and Program Development; Ginger Gossman, PhD, Researcher; and Susan Rodriguez, Texas Child Fatality Review Team Coordinator. Bobby Schiener, of the Texas Vital Statistics Unit and John Hellsten, PhD, of the Epidemiology and Disease Surveillance Unit also contributed to the preparation of this report. This report would not be possible without the dedication and input of the members of the SCFRT (Appendix A) and the local Child Fatality Review Team coordinators, presiding officers and respective team members (Appendix B). The wide array of professionals who volunteer as members of their local teams give the child fatality review process its multi-disciplinary flavor and add immeasurably to the goal of understanding child death in Texas and reducing safety risk to Texas children. Their commitment to preventing child death is saluted. The Office of Title V and Family Health, DSHS, funded the development and production of this report. Questions about the report should be directed to: Eric Levy, MD Chair, State Child Fatality Review Team Committee ATTN: Susan Rodriguez, Texas Child Fatality Review Team Coordinator Texas Department of State Health Services 1100 W. 49th St. Austin, TX 78756 (512) 458-7111 ext. 2311 susan.rodriguez@dshs.state.tx.us

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LETTER FROM THE CHAIR

“We are guilty of many errors and many faults, but our worst crime is abandoning the children, neglecting the fountain of life. Many of the things we need can wait. The child cannot. Right now is the time… we cannot answer ‘Tomorrow’; his name is today.” Gabriela Mistral (pseudonym of Lucila de María del Perpetuo Socorro Godoy Alcayaga), 1945 Nobel Laureate for Literature It is the hope of all of us who participate in the process of reviewing, analyzing, reporting, and extracting recommendations on child fatality in Texas, that you, the reader, will find this report valuable in your ongoing efforts at reducing and eventually eliminating preventable child deaths. Since our last report, Denise Oncken, our immediate past chair, expertly, diligently, and with remarkable strength and wisdom, guided the State Child Fatality Review Team (SCFRT) Committee through some very significant and, at times, difficult events and transitions. Some of the team accomplishments are:

• Completion of the transition from The Department of Family and Protective Services to the Department of State Health Services, Office of Title V and Family Health.

• Renewed and reenergized training as a result of the dedication of our full-time coordinator partnering with the Children's Advocacy Center in Houston, with the 2007 conference being the most successful since the inception of the State Child Fatality Review Team Committee.

• Significant involvement of the SCFRT on the Protecting Texas Children Conference. • The publication of the 2006 Annual Report and a marked increase in building and

sustaining relationships. • Guiding local teams through the conversion to the National MCH Child Death Database. • Fostering prevention activities by local teams based on the available data for effective

planning and program implementation. • Panel presentation about the partnership between Child Fatality Review and the

Children's Advocacy Centers at the Children’s Advocacy Centers of Texas Annual Conference, resulting in building new teams and re-activating inactive teams through the Children’s Advocacy Centers network.

• Collaboration with the DSHS Health Service Regions to partner with local teams to help organize and build new teams.

The annual conference held in conjunction with the Houston Children's Advocacy Center with additional support from the Harris County District Attorney’s Office, Harris County Child Abuse Task Force, Harris County Sherriff’s Department, and Texas Children’s Hospital provided a sense of renewed focus and direction with a wide range of topics, including: medical child abuse; co-sleeping and promoting safe sleep; risks for children with special needs; Fetal Infant Mortality Review (FIMR); child abuse and domestic violence; suicide prevention; the design, implementation and evaluation of injury prevention programs; Sudden Unexplained Infant Death investigation; the prevention of child deaths in motor vehicle crashes; CFRT best practices and compassion fatigue.

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We have many challenges ahead, including the goal to review all child deaths in Texas, continuing to strengthen existing laws and increasing collaboration with existing prevention groups, State leadership and the Legislature, and Texas citizens to eliminate those preventable deaths. We look forward to achieving new levels in both review and prevention, strengthening existing relationships, and capitalizing on new opportunities to ensure a brighter, safer future for Texas children and their families. Eric N. Levy, MD Chair, State Child Fatality Review Team Committee

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READING THIS REPORT

This report is divided into three chapters:

1. Operations & Activities 2. Recommendations 3. Data & Analysis

Chapter 1: Operations & Activities includes a thorough description of the child fatality review (CFR) process. This chapter addresses the legislative authority for the CFR process in Texas, a description of the data and the case reviews, and information on the number and distribution of teams. Chapter 2: Recommendations includes policy and programmatic ideas that, if implemented, may improve our understanding of child death or contribute to the prevention of child death. These recommendations incorporate ideas from the local teams in addition to the expertise of the members of the SCFRT and are based on data found in Chapter 3: Data & Analysis. Chapter 3: Data & Analysis is an overview of child death in Texas that includes mortality by county and data on Sudden Infant Death Syndrome (SIDS) and several causes of intentional and unintentional injury deaths (drowning, motor vehicle crashes, homicide, firearm deaths, and suicide). Trends in the data are presented along with information on gender, race/ethnicity, and age disparities. Information presented in this chapter includes data from local child fatality review teams as well as from the Texas Vital Statistics Unit.

Chapter 1: Operations & Activities

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WHAT TO EXPECT IN THIS CHAPTER

This chapter describes the operation of child fatality review (CFR) in Texas, including a description of Chapter 264, Subchapter F of the Texas Family Code and the statutory authority for the CFR process in Texas. An overview of the roles of the local and state child fatality review teams (CFRTs) is provided along with the data sources and their limitations. This chapter also provides a detailed description of the active CFRTs throughout Texas. Statistics pertaining to the population and number of deaths covered by the active teams are included along with a discussion of the number and proportion of cases reviewed over time. Annually, local CFRTs are asked to provide highlights of the year’s activities for inclusion in this report. This year ten teams provided information, which is included in this chapter. While highlighting their achievements, this section also shows the regional differences and challenges confronted throughout Texas. Also spotlighted in this chapter are the critical partnerships with Children’s Advocacy Centers and the value of CFRT contributions.

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OPERATIONS

An Overview of Child Fatality Review in Texas Child fatality review has been in operation in Texas since 1995 when the creation of the child death review process was mandated by the Texas Legislature. As envisioned in the statute, Texas Family Code, Title 5, Chapter 264, Subchapter F, §264.501 - §264.515 (see Appendix C), child fatality review consists of two components – the State Child Fatality Review Team Committee and Local Child Fatality Review Teams – each with distinct yet complementary roles. Role of the State Child Fatality Review Team Committee The State Child Fatality Review Team (SCFRT) Committee is a statutorily-defined multi-disciplinary group of professionals who serve to:

• develop an understanding of the causes and incidences of child deaths in Texas; • identify procedures within the agencies represented on the committee to reduce the

number of preventable child deaths; and • promote public awareness and make recommendations to the Governor and the

Legislature for changes in law, policy and practice to reduce the number of preventable child deaths.

The SCFRT Committee meets quarterly to discuss issues related to child safety, to address issues related to child death data collection and analysis, and to determine recommendations that will make Texas much safer for children. To achieve its goals, the SCFRT works closely with local Child Fatality Review Teams across the state, which are the mechanism by which data are collected and child safety issues are identified at the grassroots level. Role of the Local Child Fatality Review Teams Child Fatality Review Teams (CFRTs) are multi-disciplinary and multi-agency groups of professionals who volunteer to regularly review child (under the age of 18 years) deaths in the designated area in order to understand risk to children and to reduce the number of preventable child deaths. Typically, teams correspond to a given county, although the statute provides for multi-county teams in areas with a population of less than 50,000. A local team, in reviewing child deaths, is charged with:

• providing assistance, direction and coordination to investigations to child deaths; • promoting cooperation, communication and coordination among agencies involved in

responding to child fatalities; • developing an understanding of the causes and incidence of child death in the county or

counties in which the review team is located; and • advising the SCFRT Committee on changes to law, policy or practice that will assist the

team and the agencies represented on local teams in fulfilling their duties.

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Ultimately, the mutual role of the local teams and the SCFRT Committee is to help prevent future child deaths. Local teams collect data, identify local child safety issues, and address them through education and prevention initiatives. In submitting local data, local teams together create a detailed picture of child death as a public health issue in Texas. The State Committee, in turn, acts on behalf of the local teams based on the collective data and the recommendations of the local teams. Legislative Authority and State Agency Involvement Senate Bill 6, passed by the 79th Texas Legislature, amended the Texas Family Code to move the oversight of the child fatality review process from the Department of Family and Protective Services (DFPS) to the Department of State Health Services (DSHS). However, DFPS remains an important partner in the child fatality review team process. For DSHS to comply with the legislative mandate regarding CFRTs, multiple components of the agency must be involved in providing support and direction to the local teams (Figure 1). DSHS staff and programs enhance child fatality review in Texas by working together to help teams collect and interpret child death data and turn knowledge into prevention initiatives. The organizational home of the child fatality review process is within the Division of Family and Community Health Services, the Office of Title V and Family Health. Within that Office, the Texas Child Fatality Review Team Coordinator is in the Family Health Research and Program Development Unit. The role of the Coordinator is to:

• provide support and training to the local teams, • develop new teams in areas without coverage, • support the SCFRT in their quarterly meetings, • create processes and procedures for effective teams meetings and data collection, • assist the teams in implementing prevention programs on a community level, and • facilitate communication among the team, the local teams, SCFRT and DSHS staff.

The Texas Vital Statistics Unit, which is housed in the Office of the Chief Operating Officer, has traditionally played a significant role in the child fatality review process. The Texas Vital Statistics Unit is responsible for the annual distribution of over 3,000 death certificates and 1,500 birth transcripts to the local CFRTs. The absence of this information would severely limit the ability of local CFRTs to function. In mid-2007, with funding from the Office of Title V and Family Health, staff members from the DSHS 11 Health Service Regions were identified to help understand the causes of child deaths and how those deaths can be prevented. Child death review is now part of the regional plan for population-based services developed by each of the Health Service Regions. As part of this plan, regional staff assist in developing new CFRTs and serve as the voice of public health and prevention on existing teams. DSHS regional staff have been trained on the CFR process and are working with the Texas CFRT Coordinator to identify potential partners, convene community information meetings, organize new teams and work with teams and communities on prevention initiatives. The impact of a statewide focus on Child Fatality Review will be reflected in the

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2008 Annual Report through added CFRT coverage across the state, supplementary data and additional prevention efforts. In addition to the support provided by DSHS staff, the State Registrar, who heads the Vital Statistics Unit, and the Director of the Office of Title V and Family Health are both permanent members of the SCFRT. The Commissioner of the Department of Family Protective Services is the third permanent member of the SCFRT (Title 5, Chapter 264, Subchapter F, Texas Family Code, §264.502).

Division of Family and Community Health Services

Evelyn Delgado

Assistant Commissioner

Office of Title V and Family Health

Fouad Berrahou

Director and CFRT Member

Family Health Research and Program Development Unit

Brian Castrucci

Manager

Office of the Chief Operating Officer

Dee Porter

Chief Operating Officer

Vital Statistics Unit

Geraldine Harris Manager and CFRT Member

Figure 1. DSHS Support of CFRT

Family Health Research and Program Development Unit

Susan Rodriguez

Texas CFRT Coordinator

Department of State Health Services

David Lakey, MD

Commissioner

Division of Regional and Local Health Services

Janet Lawson, MD

Assistant Commissioner

Staff in each of Texas’ 11 Health Service Regions work to prevent childhood injury

and death

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DATA AND LIMITATIONS

Statistical analyses of data derived from local CFRT reviews are an important facet of the child fatality review process. Analyses of these data provide a more thorough and comprehensive understanding of the causes and circumstances surrounding child fatalities in Texas. Whereas information from the death certificate provides the demographic characteristics of child fatalities, only the more detailed information available from CFRT reports can indicate the specific information regarding how, where, and under whose supervision an event occurred. This provides a more complete understanding of the scope and nature of child fatalities in Texas that can be used to suggest preventive interventions. Overview of Vital Statistics Data Texas Vital Statistics mortality data come from the death certificate. Death certificates are completed by funeral directors and medical certifiers (physicians, medical examiners or justices of the peace). Generally, funeral directors provide the decedent's demographic information, including the name, sex, date of death, social security number, age at last birthday, birth date, birthplace, race, current address, usual occupation, educational history, service in the U.S. armed forces, site and address of death, marital status, name of any surviving spouse, parents' names, and informant's name and address. They also include the method and site of body disposition (burial, cremation, donation, or other) and sign the form. The responsible medical certifier then completes, with or without using an autopsy, the medical certification section of the certificate. This includes the immediate cause(s) of death; other significant conditions contributing to the death; the manner of death; the date, time, place, and mechanism of any injury; the time of death; the date the death was pronounced; whether the medical examiner was notified; and his or her signature. The death certificate then is registered with the responsible local and state government offices. The death certificate then is registered with the state's vital statistics office and from there to the United States Center for Health Statistics. Annually, a final data file is prepared and serves as the official record of mortality in Texas. The most recent final file is for deaths occurring in Calendar Year 2004. Data included in this report from 2005 are provisional data. Provisional data are not final and are subject to change as data entry errors are identified and corrected. Therefore, data presented in this report using 2005 death certificate data may change when a final file is issued. If changes in the final file alter interpretation, trends, or conclusions presented in this report using the provisional 2005 death certificate data, a section will be added to the 2008 Annual Report that will include corrections and updated data. Overview of Child Fatality Review Team Data Data from the reviews conducted by local teams are entered into a national system developed by the National Maternal and Child Health Center for Child Death Review, in collaboration with state programs. Given the volume of deaths and the volunteer nature of local CFRTs, teams may choose not to review all deaths. Many programs in the United States, including some Texas teams, do not review natural deaths with the exception of SIDS. Thus, case selection is an

6

important factor when interpreting child death review data. Case selection depends on several factors such as geographic area, number of deaths, access to information, and meeting frequency. The deaths reviewed by CFRT teams are culled from all deaths that occur in Texas. Thus, the mortality data taken from Vital Statistics includes deaths to Texas residents and deaths to non-Texas residents who died in Texas. Of the 4,122 child deaths reported in the 2005 provisional Vital Statistics data, 122 were of non-Texas residents. This is an important point given that teams are engaged in local efforts to reduce mortality in their area. Their efforts not only impact local residents, but also visitors from other counties, states and countries. This is especially true in cases where local infrastructure can prevent mortality. For example, fences around pools can prevent drowning. Also, visible signage and a clear line of sight can prevent motor vehicle crashes. CFRT data have several limitations, one of which is missing or unknown values. Specific information about the circumstances of death is not always available for all reviewed deaths, therefore the number of cases in which the information was available is noted within each table and chart. These unknown values are difficult to interpret and may indicate the presence of social desirability bias (the inclination to underreport behaviors that are not consistent with current social recommendations). For example, a mother who has lost a baby to SIDS may not reveal that the infant was placed on his stomach to sleep, which is in contrast to public health recommendations. Since several reviews involve criminal proceedings, the prevalence of unknown values may indicate a person’s desire to conceal aspects of the death that may be incriminating. While it is impossible to know why values may be missing, it is important to consider the prevalence of unknown values when interpreting findings. Another limitation of CFRT data is the absence of data collection and submission standards. There are local CFRTs that do not review all of their deaths. They may choose to focus solely on injury deaths or may only submit to the Child Death Registry those injuries that are preventable. These practices introduce bias into the CFRT data. Increasing standardization and rigor in data collection is a programmatic goal. To this end, Texas has opted to input data into the National Child Death Review Data Collection System (National System), based within the Michigan Public Health Institute, National Maternal and Child Health Center for Child Death Review. Transition to the National Child Death Review Data Collection System Inputting data into the National System will benefit Texas CFR by (1) implementing a nationally standardized form for data entry and (2) allowing for comparison with CFR data from other states. In 2005, child fatality review team data were collected during the period of transition from the Texas data collection tool to the National System. While deaths were reviewed using the former instrument, all 2005 data were entered in the National System. While this decision facilitated the transition to the National System, it was not without consequence. Though all of the 2005 data were entered in the National System, the instruments were similar, but not congruous. State CFRT staff collaborated on reviewing and cross-walking the two data instruments to ensure as complete a data transition as possible. Despite these efforts, child fatality review team data in 2005 has a high rate of unknown or missing values. The effects were most evident among those fields that were most different between the Texas data collection tool and the National System. This challenge is expected to impact only the 2005 data. By 2006, all local teams were using the National System’s data collection instrument.

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COVERAGE BY LOCAL CHILD FATALITY REVIEW TEAMS Status of Child Fatality Review Teams, 2005 An active team is defined as any team reviewing at least one death annually and submitting data to the National Child Death Review Data Collection System. During 2005, there were 27 active local child fatality review teams in Texas (Map 1). These teams encompass 95 of Texas’ 254 counties. These counties included 71% of the under 18 population in Texas in 2005 (based on population estimates for 2005). Of all deaths in 2005 occurring among children who were less than 18 years of age, 82% resided in counties with active local CFRTs, although not all deaths were reviewed. In 2005, 34.7% of all deaths were reviewed (1,429 reviewed out of 4,122 child deaths) (Chart 1). From initial calendar year 1995 to 2005, the proportion of reviewed deaths ranged from a low of 26.6% in 1995 to a high of 60.3% in 2002.

Map 1. Active Child Fatality Review Teams, 2005

Map provided by Texas DSHS, Family Health Research and Program Development

Active Local CFRTs

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0

500

1000

1500

2000

2500

3000

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 20050

10

20

30

40

50

60

70

Number Proportion

Source: Texas Child Death Registry, 1995-2004 Texas Data from National System, 2005

Chart 1. Number and Proportion of Child Deaths Reviewed, 1995 through 2005

#

%

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The proportion of deaths reviewed by local teams ranges from 14% to 100% across the 27 teams (Map 2).

Map 2. Proportion of Deaths Reviewed by Team, 2005

There were 157 counties that did not have a CFR process in place in 2005. These counties accounted for 18% of all deaths to children less than 18 years of age. It is a goal of the SCFRT and staff dedicated to CFR to reinvigorate the teams that have become inactive and to start new teams in areas without a team. Status of Child Fatality Review Teams, 2007 While the data presented in this report address mortality during 2005, included is information on changes in the location and number of teams between 2005 and 2007. As of December 31, 2007, there were 31 active local CFRTs in Texas (Map 3). These teams encompass 101 of Texas’ 254 counties. These counties include 72% of the under 18 year old population in Texas (based on population projections for 2007).

Source: Texas DSHS, VSU Map provided by Texas DSHS, Family Health Research and Program Development

≤ 25%

≥ 75%

51% to 74%

26% to 50%

No team coverage

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Map 3. Active Local Child Fatality Review Teams, 2007

1. Bastrop County CFRT

17. Madison/Leon County CFRT

2. Bexar County CFRT 18. McLennan County CFRT 3. Brazos County CFRT 19. Nacogdoches County CFRT 4. Burleson County CFRT 20. Orange County CFRT 5. Cameron/Willacy CFRT 21. Panhandle CFRT 6. Central Texas CFRT 22. Smith County CFRT 7. Collin County CFRT 23. South Plains CFRT 8. Concho Valley CFRT 24. Tarrant County CFRT 9. Dallas County CFRT 25. Travis County CFRT 10. Ellis County CFRT 26. Tri-County CFRT 11. El Paso County CFRT 27. Victoria County CFRT 12. Galveston County CFRT 28. Walker County CFRT 13. Grayson County CFRT 29. Washington/Grimes County CFRT 14. Houston/Harris County CFRT 30. Webb County CFRT 15. Hunt County CFRT 31. Williamson County CFRT 16. Jefferson County CFRT

Map provided by Texas DSHS, Family Health Research and Program Development

1

2

8

30

5

11

27 12

16 20

6

25 31

18

10 24

7 13

15 9

3 4

29

14

17 28

22 26

19

21

23

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TEXAS CHILD FATALITY REVIEW AT THE COMMUNITY LEVEL

Texas Child Fatality Review Teams (CFRTs) are tenacious in working toward determining the critical details of child deaths and utilizing these details to develop and support effective prevention initiatives. The composition of teams includes disciplines that interact with incidents of or issues surrounding child death, including law enforcement, health care, social services and advocates. Team members enter into a partnership, agree to share information within the confidential environment of a review team meeting and pool their resources by partnering on prevention initiatives. Information on how to start a local CFR team in your community is included in Appendix D. One partnership that stands out in Texas child fatality review process is the partnership with the Children’s Advocacy Centers (CACs). Local CACs throughout the state are actively involved in child fatality review, and many teams continue to thrive with leadership and coordination provided by these centers. Of the 27 teams that were active in 2005, CACs were at the helm of 11 teams; of the 31 active teams in 2007, 12 are coordinated by this outstanding partner.

Map 4. Local CFR Teams with CAC Leadership, 2007

Another critically important relationship between CFRTs and CACs is the partnership between the SCFRT Committee and the Children’s Assessment Center of Houston. For at least three years, these two groups have partnered on the planning and execution of the annual multi-disciplinary Protecting Texas Children conference. This collaboration provides an outstanding professional training opportunity for the diverse members of the Texas CFRTs, strengthens the strong partnership between Child Fatality Review and CACs, and is gaining in recognition as a leading conference for child fatality review content. The 9th Annual Protecting Texas Children conference, held in Houston October 1 through 3, 2007, was attended by 300 people, 70 of whom were CFRT member attendees from Texas as well as Hawaii, Delaware, Washington, D.C., and British Columbia, Canada.

• Bastrop County CFRT, Children’s Advocacy Center of Bastrop • Bexar County CFRT, ChildSafe of San Antonio • Central Texas CFRT (multi-county team), Children’s Advocacy Center

of Central Texas • Collin County CFRT, Collin County Children’s Advocacy Center • Concho Valley CFRT (multi-county team), Hope House Children’s

Advocacy Center of Tom Green County • Galveston County CFRT, Advocacy Center for Children of Galveston

County • Grayson County CFRT, Children’s Advocacy Center of Grayson County • Jefferson County CFRT, The Garth House/Mickey Mehaffy Children’s

Advocacy Program • McLennan County CFRT, Advocacy Center for Crime Victims and

Children • Orange County CFRT, The Garth House/Mickey Mehaffy Children’s

Advocacy Program • Travis County CFRT, Center for Child Protection • Webb/Zapata Counties CFRT, Children’s Advocacy Center of Webb

County

CAC Led Team

Other Active CFRT

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Children’s Advocacy Centers of Texas, Inc., the statewide membership association representing all local CACs in Texas, recognized the link between the CACs and CFRTs at their annual conference in October 2007. A panel discussion about this connection included the Chair of the State Child Fatality Review Team Committee, the Texas CFRT Coordinator, and representation from four CACs that coordinate local teams. The Value of Volunteerism Local CFRTs are volunteer-based. With the exception of the Dallas County and Houston/Harris County CFRTs, each of which has a paid staff person to coordinate the team, all Texas teams are made up of individuals who volunteer to serve on the team. From the First Responder who brings his report of the scene at the site of the motor vehicle crash, to the neonatologist who reports on the circumstances of a premature birth and death, to the county sheriff who describes the scene of a homegrown meth lab explosion, all CFRT members are professionals who donate their time and energy to identifying and reducing risk to children. Such volunteerism deserves recognition. Up until this point, the Texas CFRT program has not formally collected CFRT member volunteer hours, but a survey of several teams paints a vivid picture of the kind of time invested and the value of that time. Using the calculations of the Independent Sector (www.independentsector.org), the national leadership forum for the charitable and philanthropic sector, the value of time donated by volunteers in Texas in 2005 was estimated to be $18.20 per hour. This figure may underestimate the value provided by CFRT members given the specialized skills required of team members. Table 1 presents the real dollar value of the expertise and time donated in reviewing child death in a sample of local CFRTs.

Table 1. The Value of Volunteerism

Team Name # Meetings/ Year

Length of Meetings

Average Attendance

Member Prep Time

per Meeting

Coordinator Prep per Meeting

Data Entry Time per Meeting

Total Hours per Year

Collin County 11 1.5 hours 11 15 minutes 1.5 hours 2 hours 399

El Paso County 10 1.5 20 1 hour 1 hour 2 hours 530

Galveston County 4 2 hours 10 1.5 hours 3 hours 3 hours 164

South Plains 4 3 hours 15 1.5 hours 10 hours 16 hours 374 Tarrant County 10 1.5 hours 20 2 hours 10 hours 10 hours 900

Travis County 6 2 hours 20 2 hours 5 hours 10 hours 570

Victoria County 3 2 hours 15 1 hour 2 hours 2 hours 147

TOTAL Number of volunteer hours in 7 Texas CFRTs: 3,084 VALUE of annual volunteer hours for 7 Texas CFRTs: $56,128.80

Reducing the Risk through Prevention Activities

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The Texas teams take seriously the charge to understand why children are dying and, based on the data for given areas, to focus on reducing risk to children to minimize preventable child death. The profiles below spotlight the dedication and distinctly local flavor of CFRT activities. Dallas County Child Fatality Review Team This urban team is one of the first CFRTs established in the state. Since late 2006, the team has been coordinated by the Injury Prevention Center of Greater Dallas, which is affiliated with Parkland Health & Hospital System. Given that Parkland Hospital is a Level I Trauma Center, the second largest regional burn center in the U.S., and the busiest birthing hospital in the nation and second busiest in the world, the Injury Prevention Center is a natural and logical adjunct to the hospital and a natural and logical agency to take the leadership role in Child Fatality Review. In 2007, the team dramatically improved the rate of child death review in the state’s second most populous city, and they are moving toward 100% review of all deaths. The Presiding Officer and Coordinator of the Dallas County CFRT prepared and presented a two-part session at the Protecting Texas Children conference on “Design, Implementation and Evaluation of Injury Prevention Programs.” Galveston County Child Fatality Review Team The Galveston County CFRT is led by the Advocacy Center for Children of Galveston County. This 16-member team includes a strong law enforcement presence from the many jurisdictions in the Gulf Coast county. As a means to improve child death scene investigation, the team distributed a pocket-sized Child Death/Injury Interview and Intervention Guide to all possible responders who might answer a child death scene call. This guide has possible interview questions, lists what to look for when making observations about the home environment, child and caregiver. The team also used resources to send team members to professional training.

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Victoria County Child Fatality Review Team This South Texas Team, under the sponsorship of Citizens Medical Center, has worked on preventing child death in motor vehicle crashes and by suicide. Several team members went to car safety seat installation training to be certified to run car safety seat clinics. The team also has followed up on CFRT-established Teen Helpline after several years to gauge teen awareness of the resource. Based on the feedback, the team is working on revisiting the issue with schools and working with the media to renew awareness of this resource for South Texas teens. The team is also considering expanding its area of service to review child deaths in neighboring Dewitt and Lavaca counties. Smith County Child Fatality Review Team This east Texas team is led by local Child Protective Services and utilizes child safety campaigns developed by the Department of Family and Protective Services (DFPS). The team implemented a campaign in conjunction with DFPS and the Children’s Advocacy Center of Smith County (See and Save Campaign) to educate the public on the dangers of leaving children in cars. The team is also very interested in pursuing safety messages about children and all-terrain vehicles (ATVs): the need for helmets and supervision, and when such activities as riding or driving ATVs are beyond the child’s developmental capabilities.

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McLennan County Child Fatality Review Team This team, under the leadership of the Advocacy Center for Crime Victims and Children, has taken the initiative to expand beyond the county and incorporate four outlying counties into the team. Working with Hillcrest Hospital and the Heart of Texas Trauma Regional Advisory Council, the team is expanding to become the Heart of Texas Child Fatality Review Team in 2008. As part of the Heart of Texas CFRT, McLennan, Bosque, Hill, Limestone and Falls counties will work together to review child deaths and focus on regional prevention efforts. Hunt County Child Fatality Review Team This northeast Texas team is coordinated by the Trauma Coordinator of Presbyterian Hospital of Greenville. The team engaged in multiple prevention activities to reduce preventable child death. The team developed and distributed a safe sleep brochure that is given to all new parents before they leave the hospital. The brochure is being translated into Spanish as well. Three members of the team have been certified to conduct child safety seat clinics, which are held monthly at the hospital as well as an annual city-wide clinic. The team is pursuing funding to sponsor a Shattered Dreams program for teen drivers in an identified higher-risk part of the county.

CAR SAFETY SEAT CLINIC IN HUNT COUNTY

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Houston/Harris County Child Fatality Review Team This team, led by Harris County Public Health and Environmental Services, has a strong commitment to prevention activities. In 2007, the team was a lead partner in the 24-agency SafeKids Greater Houston Water Safety Coalition 2nd Annual April Pools Day event. This water safety event was held at a YMCA in conjunction with a health fair for families, and included exhibits on boating, proper selection and use of child life jackets and pool covers. Instructional presentations about near drowning, submersion deaths, availability of swimming instruction in the greater Houston area and CPR instruction were also provided. Swimming lessons were raffled off to attending children. The event received considerable media coverage and put water safety at the forefront as the pools opened. The team also selected a second prevention project, “Think about the Link,” which is based on the connection between child abuse and animal abuse. Team members have received training on this topic; a Houston Humane Society’s animal cruelty investigator has joined the team, and a team member for the Houston Police Department is now training other officers on interviewing children about their pets and treatment of pets as a standard part of child abuse and domestic violence investigations. HOUSTON/HARRIS COUNTY APRIL POOLS DAY EVENT TO INCREASE DROWNING AWARENESS

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South Plains Child Fatality Review Team This 22-county team in northwest Texas has leadership through the Texas Tech Health Science Center Department of Pediatrics. The team places emphasis on education about the vulnerability of infants and young children, collaborating with other agencies on the Never Shake a Baby campaign, working with the Children’s Advocacy Center of South Plains on their annual child abuse prevention conference, and making presentations to Texas Tech nursing students and to the public on child abuse awareness and reporting. The team is also collaborating with the Altrusa Club on an initiative to provide cribs to low-income families with infants. Tarrant County Child Fatality Review Team This team, which reviews deaths from Tarrant, Parker and Denton counties, is led by the Tarrant County Medical Examiner’s Office. In 2007, members of the Tarrant County CFRT developed and conducted 14 professional trainings on conducting child abuse investigations, Shaken Baby Syndrome and abusive head trauma, drug-endangered children and child fatality review. The trainings have been delivered to over 1900 persons around the state. Other members of the team have assisted in the development of Fetal Infant Mortality Review (FIMR) in targeted zip codes in Fort Worth and will continue as consultants on the FIMR project. Tri-County Child Fatality Review Team This team, covering Harrison, Panola and Rusk counties, is under the long time leadership of the Panola County Sheriff’s Office. Sheriff Jack Ellett, Presiding Officer and former Chair of the State Child Fatality Review Team Committee, makes it his mission for his constituency to know about safety risks to children in his weekly radio program and newspaper column. Gearing the message to the season or recent events, he has shared information about water safety in the summer, motor vehicle safety at prom time, the need for bicycle helmets, properly installed child safety seats and safe sleep for infants. This team also serves as a mentor for other east Texas communities starting CFRTs.

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Travis County Child Fatality Review Team This central Texas team, co-led by the Travis County District Attorney’s Office and the Center for Child Protection, has a long tradition of developing an annual report for the community about child deaths and recommendations for prevention. The team has a 12-year historical database on child deaths upon which they base their studies of trends and their calls for action for reducing preventable child death. In April 2007, the team released their findings for the prior year in a press conference that featured the Mayor of Austin, the Travis County District Attorney, the Travis County Sheriff and many other dignitaries. The event and the information received much attention in the Central Texas press. To see the report visit http://www.centerforchildprotection.org/assets/Media_Publications_PDF/CFRT/cfrt06_ltrfinal-5-1-07.pdf.

TRAVIS COUNTY CHILD FATALITY REVIEW TEAM’S ANNUAL REPORT

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NOTABLE ACTIVITIES AND COLLABORATIONS IN 2007

2007 Protecting Texas Children Conference The 2007 Protecting Texas Children Conference held in Houston in October was a successful professional conference and training event for those involved in child death review. Members of the SCFRT and the Texas CFRT Coordinator served actively on the Planning Committee for the conference, and the CFRT Coordinator served as the Chair of the Program Committee. Of the 300 in attendance at the conference, 70 were CFRT and SCFRT members, plus a large contingent of DSHS regional staff attended the conference to orient themselves to child death review as they begin to incorporate it into their Title V-funded population-based services. Funding from the Office of Title V and Family Health reimbursed expenses of up to two people per team to attend the conference. The conference was an excellent opportunity for members of CFRTs to meet and compare challenges and successes in the review process, as well as a great opportunity for them to meet people from like disciplines committed to the multi-disciplinary approach to the protection of children. The challenges of planning a conference for such a wide audience was successfully met, with concurrent sessions addressing law enforcement issues, child abuse identification and treatment, legal issues and child fatality review. A review of the evaluations for the sessions indicate that this conference was very well-received by the attendees.

• “Excellent” and “more time needed” were comments made in response to Dr. James McKenna’s presentation on “Promoting Safe Sleep;”

• “Great speaker, great presentation,” “need more time” and “excellent” were the responses to Dr. Chris Greeley’s sessions on “Abusive Head Injury” and “Child Neglect: What It Is and What It’s Not;”

• “Great,” “well-prepared” and “interactive” were the feedback for the “Sudden Unexplained Infant Death Investigations” training offered by the Texas SUIDI Training Team;

• “Fabulous,” “excellent!,” “moving” and “best workshop of the conference” were the kudos received by Trooper Garry Parker, Department of Public Safety, who received perfect evaluations, for his presentation “Preventing Motor Vehicle Crash Deaths Involving Children;” and

• “The best conference I ever attended” was the feedback from a group of public health staff attending the conference.

The plan for 2008 is to continue partnering with the Children’s Assessment Center of Houston, with an extended pre-conference session exclusively for CFRTs.

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Improving Collaboration: Child Fatality Review Team Members, DSHS, and DFPS There are numerous ways in which DSHS and DFPS collaborate to make Texas a healthier place for children. Historically, when DFPS had oversight over the CFRTs, DSHS was involved and responsible for the data collection and analysis, the basis for identifying and reducing risks to children through prevention initiatives. Now that DSHS has oversight of child death review, DFPS continues to be a critical partner in many different ways. DFPS is an important presence on the SCFRT Committee and on local teams, where caseworkers can provide critical insight into child deaths where there was a history of abuse or neglect. A group of SCFRT members serve on the DFPS Child Safety Review Committee and submit annual recommendations on improving Child Protective Services (CPS) operations. The agencies collaborated in 2007 on the topic of safe sleep for infants. Given the number of infant deaths in sleep environments reviewed by the local teams and by CPS, and the diversity of opinion about most effective practices and strategies for prevention, the issue of safe sleep has been identified as one of mutual interest. In the Texas Child Fatality Review Team Annual Report 2006, the data indicated that the rate of prior DFPS involvement among children who die of SIDS was at least 10 percentage points greater than the rate among all other infant deaths each year from 2000 to 2004. This is an issue that merits more attention and study, and it is also an issue that the Prevention and Early Intervention arm of DFPS focused on when looking to do targeted education and intervention around safe sleep issues. DFPS and DSHS both serve on the Safe Sleep Workgroup of the SCFRT Committee. Expanding Injury Prevention Activities Findings from the reviews of local teams indicate a need for increased injury prevention activities in Texas. While many local teams have implemented injury prevention activities, a need exists for improved state coordination. To improve the state’s response to injury morbidity and mortality, planning began in 2007 to identify funds available in State Fiscal Year 2009 (September 2008 through August 2009) for community-based organizations and other eligible organizations to implement an evidence-based project (see Nansel TR et al. Preventing unintentional pediatric injuries: a tailored intervention for parents and providers. Health Education Research. 2007 Sep 28 [Epub ahead of print] ) that incorporates injury prevention messages into primary care settings followed by tailored messages to parents several weeks after the initial primary care visit. Planning for this initiative has included discussions of the unique role that local teams could have in providing information and direction to funded organizations. Additionally, collaboration between the Division of Family and Community Health Services, Division of Mental Health and Substance Abuse, and Division of Prevention and Preparedness has led to the creation of an injury prevention workgroup to explore opportunities for collaboration around injury prevention. As part of the workgroup, DSHS is pursuing a new opportunity that will provide an assessment of the current injury and violence prevention efforts in the department. DSHS plans to invite the State and Territorial Injury Prevention Directors Association (STIPDA) to send a State Technical Assessment Team (STAT) to assess injury prevention within the state health agency. The assessment focuses on the core components of a successful state health department injury prevention program including:

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1) Infrastructure; 2) Data collection, analysis, and dissemination; 3) Intervention design, implementation, and evaluation; 4) Technical support and training; and, 5) Public policy and advocacy. The process brings a team of injury prevention experts into a state for a five-day site visit. During the visit, the team interviews the staff and partners of the state’s injury prevention program and assesses the capacity of the program to conduct primary prevention at that point in time. The team also produces a report on-site which describes the status of the program and makes recommendations for its advancement.

CDC-Sponsored Sudden, Unexplained Infant Death Investigation (SUIDI) Initiative Comes to Texas

It is estimated that more than 4,500 infants die annually across the nation with no apparent cause of death. Approximately half of sudden infant deaths nationwide can be attributed to Sudden Infant Death Syndrome (SIDS). By definition, SIDS can be diagnosed only after a thorough examination of the death scene, a review of the clinical history, and an autopsy fail to find an explanation for the death. Understanding the other fifty percent of infant deaths has become challenging because of lack of standardized investigation and reporting of those deaths. Some infant deaths are not investigated and, when they are, cause-of-death data are not collected and reported consistently. This is problematic because inaccurate classification of cause and manner of death ultimately impacts understanding why these infants died and how to best approach prevention.

In 2006, the Center for Disease Control (CDC) launched an initiative to standardize and improve the investigation and reporting of the sudden deaths of infants. The Sudden, Unexplained Infant Death Investigation (SUIDI) Reporting Form was released to help create a uniform standard for investigation and data collection in understanding these deaths. In conjunction with the reporting form, the CDC systematically conducted Training Academies so that each state in the union would have a trained team of professionals to conduct training on a local level and to serve as state experts.

In 2007, Texas was asked to organize a team of specific professionals to attend the Training Academy and to serve as the Texas SUIDI Training Team. The Texas Team is comprised of the following professionals:

• Reade Quinton, MD, Texas SUIDI Training Team Lead, Office of the Dallas County Medical Examiner, forensic pathologist and assistant professor of pathology at the University of Texas Southwestern Medical Center.

• Christopher Greeley, MD, Pediatrician, Associate Professor of Pediatrics, University of Texas Health Science Center at Houston.

• Mary Brownlee, JD, Chief Investigator, Office of the Dallas County Medical Examiner • Captain James Rickhoff, Homicide, Bexar County Sheriff’s Department. • Susan Rodriguez, Texas Child Fatality Review Team Coordinator, Texas Department of

State Health Services.

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Since completion of the SUIDI Training Academy, the Texas Team has presented training to CFRT members attending the 2007 Protecting Texas Children Conference and to a pilot group of Child Protective Services (CPS) caseworkers in Travis County. It is the goal of the Texas SUIDI Training Team to train justices of the peace, medical examiners, law enforcement, First Responders, caseworkers and all others involved in death scene investigation. It is the recommendation of the SCFRT that this training be presented to all CPS caseworkers.

Achievements and Changes in the 80th Session of the Texas State Legislature The SCFRT Committee recommended the following in the 2006 Annual Report: Amendment of statutory language to change the composition of the State Child Fatality Review Team Committee to include the Texas Department of Public Safety and the Texas Department of Transportation as required members of the SCFRT Committee, and add language allowing for additional members as needed. There had been representatives from these two agencies serving on the SCFRT Committee as Ad Hoc members. DPS collects data related to child injury and fatality and brings valuable additional information to the table. TxDOT has extensive expertise in doing preventive outreach to ensure that children are in car seats that are safe and properly installed, and would be valuable partners in prevention. The expertise and applicability they brought to the Committee prompted the request that their membership in the SCFRT Committee be defined by statute. Senator Robert Nichols, District 3, sponsored the bill in the 80th Legislative Session that formally added these two members to the SCFRT Committee. Also included in the bill sponsored by Senator Nichols were proposed changes to the terms of service by committee members. The passage of this legislation staggered the terms of service of SCFRT Committee members (§264.502(c)), ensuring there will never be a complete membership turnover. The due date for the annual report was also amended from December to April to allow for more complete data to be included.

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Chapter 2: Recommendations

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WHAT TO EXPECT IN THIS CHAPTER

As part of the requirements of Chapter 264, Subchapter F, Section 503 of the Texas Family Code, the SCFRT is tasked to “make recommendations to the governor and the legislature for changes in law, policy, and practice to reduce the number of preventable child deaths.” In this report, there are six recommendations made to the Governor and State Legislature organized into two sections – Reducing Preventable Child Death and Improving Child Fatality Review Operations. Also as part of the requirements of the Texas Family Code, the SCFRT Committee is tasked to “perform the functions and duties required of a citizen review panel” and provide “recommendations regarding the operation of the child protective services system.” To fulfill this requirement, a group of SCFRT members sit on the DFPS Child Safety Review Committee where they review CPS child death cases. Based on the year-long service and input from this subcommittee, the SCFRT also provides recommendations to DFPS. While not specifically requested in the legislation, recommendations are also provided for DSHS consideration. The recommendations offered are based on:

• data presented in this report, • recommendations made by local teams, and • the expertise and experience of the SCFRT Committee.

It is the belief of the SCFRT Committee that the implementation of these recommendations will improve surveillance of child death, the function of the CFRT process at the state and local level, and lead to reductions in preventable child death.

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RECOMMENDATIONS TO THE GOVERNOR AND STATE LEGISLATURE

Legislative Recommendations to Reduce Preventable Child Death in Texas Passage of legislation to amend Transportation Code Section 545.412(a) relating to

securing of a child passenger in a motor vehicle. This recommendation is intended to improve and strengthen the child passenger safety protection law by requiring that all children younger than eight years of age, unless the child is taller than four feet nine inches (57 inches), be restrained in a child passenger safety system. Child death in motor vehicle crashes is the leading cause of unintentional, injury-related death among children 14 years and younger. Current law requires only children who are younger than five and shorter than 36 inches be secured properly in child safety seats during the operation of a vehicle. Children between the ages of four and eight and who are between 36 and 57 inches represent an age group that is at great risk of death or severe injury caused by head, spinal cord and internal organ injuries. Both the Texas Department of Public Safety and the National Highway Traffic Safety Administration recommend children use booster seats until they can fit safely into an adult lap and shoulder seat belt system which will usually occur at the height of four feet and nine inches. In addition to saving young lives, this change could significantly reduce Texas health care expenditures. According to the Texas EMS and Trauma Registry, car crashes involving children four to seven years old resulted in 900 hospitalizations, 30 deaths, 128 children with chronic disabilities and more than $16.7 million in hospital charges, where 35% of the hospitalizations were charged to Medicaid and the Children’s Health Insurance Program and an additional 20% to uninsured families (Texas Department of State Health Services, EMS/Trauma Registry, 2003 – 2004).

• Enactment of legislation that requires four-sided fencing around new residential

swimming pools. Drowning is the second leading cause of unintentional injury deaths among toddlers in Texas. SafeKids Worldwide, an international nonprofit organization dedicated solely to preventing unintentional childhood injury, estimates typical medical costs for each near-drowning victim can range from $8,000 for initial medical care to more than $250,000 for long-term care. The majority of toddler drownings occur in residential swimming pools. It is estimated that four-sided isolation fencing could prevent 50-90% of these drownings (American Academy of Pediatrics Committee on Injury and Poison Prevention. Prevention of drowning in infants, children and adolescents. Pediatrics 2003; 112(2):440-445.), yet a national survey indicates that fewer than 30% of residential pool owners have such an environmental barrier. Legislation requiring four-sided isolation fencing around new residential swimming pools would prevent unnecessary drowning deaths and reduce the burden of health care costs associated with drowning.

• Adoption of a Texas education campaign for drivers to ensure the safety of children

around vehicles. In the United States, from 2001-2003, approximately 2,500 children per year ages one to fourteen years reported to emergency rooms and an average of 229 children per year died after being struck by a vehicle in a driveway or parking area. Close to half of children injured in these incidents were one to four years of age. Texas teams have reviewed many of these tragic deaths where poor visibility prevents a parent or friend from seeing a young child behind or in front of the vehicle. Recent passage of the federal Cameron

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Gulbransen Kids Transportation Safety Act of 2007 will require the Department of Transportation to issue regulations related to power window safety, rearward visibility and rollaway prevention intended to reduce the injury of child injury and death occurring inside and near motor vehicles. In conjunction with these changes to sensing devices on vehicles, Texas can and should implement an education program for drivers as to the deadly risks to small children behind and in front of vehicles. It is recommended that TxDOT review the public education and awareness campaigns, such as Spot the Tot (a campaign developed by the Utah Department of Health and SafeKids Utah that has now been expanded to a national campaign through SafeKids USA) and put in place a similar campaign for Texas. Additionally, it is recommended that TxDOT, DPS, SafeKids coalitions throughout Texas, and other prevention organizations work in collaboration to track the effectiveness of the campaign/education efforts.

Legislative Recommendations to Improve the Effectiveness of the State Child Fatality Review Team Committee and the Child Fatality Review Operations Require all Texas counties to have an independent Child Fatality Review Team or

participate in a multi-county Child Fatality Review Team to review all deaths of children under 18 years of age. At present, approximately 82% of child deaths occur in areas of the state where there are local CFRTs. To fully understand child death in Texas and to address prevention effectively, 100% child death review coverage is recommended. A statutory requirement will reinforce Texas’ commitment to child death review and prevention, and will ensure development of teams in Texas communities without coverage.

Amend statute to alter the composition of the State Child Fatality Review Team

Committee to include an Emergency Medical Services representative and a Family Violence Service Provider. Child death review in Texas is becoming more thorough and sophisticated and the need for additional professional expertise on the SCFRT Committee has been identified. Two such areas are Emergency Medical Services (EMS) and the Family Violence community. First Responders, typically the first ones on the scene at time of critical injury and/or death, and have much to contribute in terms of scene information and investigation. These providers, as partners of trauma teams, know the need for prevention. Family violence poses a preventable risk to children and is too often a factor in child death cases reviewed by local teams. Formal addition of these team members will expand the expertise of the State Committee, which serves as a multi-disciplinary model to the local teams.

Evaluate the current Child Fatality Review statute (Texas Family Code 264,

Subchapter F, §264.501 – §264.515) to ensure that it accurately depicts the role of the State Child Fatality Review Team Committee. The purpose of the SCFRT Committee is to (1) develop an understanding of the causes and incidence of child deaths; (2) identify procedures within the agencies represented on the committee to reduce the number of preventable deaths; and (3) promote public awareness and make recommendations to the governor and the Legislature for changes in law, policy and practice to reduce the number of preventable child deaths (Texas Family Code, Title 5, Chapter 264, Subchapter F, §264.503(a)). The collective multi-disciplinary expertise and wisdom of the professionals on the SCFRT Committee, with extensive input from the local teams that conduct the child death reviews, well serves these purposes. The State Committee, however, does not review

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child deaths as is currently indicated in the statute. The Texas Family Code §264.503(f) states that “the committee shall issue a report for each preventable child death. The report must include findings related to the child’s deaths, recommendations on how to prevent similar deaths and details surrounding the department’s involvement with the child prior to the child’s death. Not later than April 1 of each year, the committee shall publish a compilation of the reports published under this subsection during the year.” Changing the statute to state that “the committee shall publish an Annual Report that is submitted no later than April 1 of each year to the governor, lieutenant governor, speaker of the house of representatives, and the department [DFPS] and is made available to the public. The Annual Report shall include aggregate data collected by local review teams as well as recommendations on how to prevent similar deaths and details surrounding the department’s (DFPS) involvement with the child prior to the child’s death” is an accurate description of how the State Committee functions.

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RECOMMENDATIONS ON CHILD PROTECTIVE SERVICES OPERATIONS Focus on strengthening caseworker investigative skills in and agency understanding of infant deaths in sleep environments. It is recommended that:

• investigative caseworkers receive training on the Sudden Unexplained Infant Death Investigation (SUIDI) protocol developed by the Centers for Disease Control and Prevention and that this protocol for infant death scene investigations be applied statewide;

• CPS develop the technological capacity to track statewide infant deaths in the sleep environment;

• CPS determine the feasibility of a statutory change requiring law enforcement, First Responders/EMS, medical examiner offices and justices of the peace to notify CPS immediately of all infant deaths in a sleep environment so CPS can be part of the investigative team; and

• CPS work with the Prevention and Early Intervention program (DFPS) and the State Child Fatality Review Team Committee and local child fatality review teams (DSHS) to develop and disseminate critical safe sleep messages to parents with infants, foster parents, kinship care providers, adoptive parents, childcare providers and the community-at-large.

Focus on developing caseworker skills in recognition, intervention and appropriate, timely referrals in cases where domestic violence poses a distinct threat to the child and family. It is recommended that:

• caseworkers receive intensive training on the dynamics of domestic violence, the impact upon children and the resources available to break the cycle and ensure family safety;

• CPS institute the use of the Lethality Assessment or a similar validated instrument as a standard investigative tool;

• CPS determine the feasibility of a statutory change requiring CPS and law enforcement mutual notification on domestic violence cases when there are children in the home; and

• agencies providing services to victims of domestic violence develop and maintain a current resource directory of Texas domestic violence prevention and support service providers that is readily available to all casework staff.

Focus on ongoing professional development, caseload management and caseworker needs to stem the high rate of caseworker burnout and attrition. In order to promote retention of well-trained, experienced casework staff, it is recommended that:

• crisis intervention services be made available for staff who have investigated child deaths or had children on their caseloads die;

• a pool of experienced caseworkers be developed to be deployed to units with vacancies or staff on extended leave so that workers do not become overburdened; and

• mentoring relationships between more experienced caseworkers and new caseworkers be formalized so that experienced workers have an opportunity to share their expertise and newer caseworkers have an additional avenue through which to build skills.

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RECOMMENDATIONS TO THE DEPARTMENT OF STATE HEALTH SERVICES

Develop a resource library and technical assistance for local teams so they may identify evidence-based model programs for population-based local injury prevention initiatives. Local teams do a good job in reviewing deaths and submitting data. Knowing how to put together effective prevention programs is more of a challenge as many of the team members from different disciplines do not have experience in program design, implementation and evaluation. Creation of a DSHS Resource Library, coupled with technical assistance from CFRT staff and DSHS regional staff, will be a great help to local teams. This will go far in applying child death data to practical prevention. Continue support of the Annual Child Fatality Review Conference for Texas teams. CFRTs operate in their own jurisdictions with oversight from the Texas Child Fatality Review Team Coordinator at DSHS. In order to reinforce standard best practices in child death review and prevention, an annual gathering of the teams is ideal. It is an efficient way to deliver consistent messages to all teams, as well as an opportunity for teams to share successes and challenges and be part of a statewide movement to protect Texas children. The 2007 Protecting Texas Children conference in conjunction with the Children’s Assessment Center of Houston was very successful because it incorporated sessions particular to the needs of CFRTs. This conference was also more widely attended by CFRT members than previous joint conferences because the DSHS Office of Title V and Family Health was able to underwrite the attendance of two members per team. It is recommended that active participation in the planning of this conference and underwriting of team member attendance continue. Increase funds allocated for training and support of new and current community volunteers serving on local Child Fatality Review Teams. CFRTs are made up exclusively of volunteers. Physicians, attorneys, law enforcement, child protective services workers, mental health providers, educators and other child advocates donate their time to serve on the local teams. In order to keep them current with training, funding is needed. The current level of funding for each team is $1,000, which is insufficient to provide training and support to the teams. Increasing the training allotment for the teams would ensure that the team members are properly trained and that child death review in Texas is expanded as new teams are developed and nurtured.

Chapter 3: Data & Analysis

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WHAT TO EXPECT IN THIS CHAPTER

This chapter includes detailed analyses of several leading causes of child mortality. After an overview of mortality trends in Texas, the chapter presents counts of an event and incidence rates for specific causes of death from death certificate information. Rates for specific causes of death (Tables 5 through 9) are calculated using population-level data provided by the State of Texas Demographer, http://txsdc.utsa.edu. The rates are category-specific. For example, the first number reported in Table 5 should be read as, “Just over two boys drowned in Texas per every 100,000 boys in Texas in 2005.” The population data used are estimates for 2005. The data used in this report were last updated in November 2006 according to the State Demographer’s website. Included in Appendix E are the population-level data used to calculate the rates presented in this report. For each cause of death, a general overview of child mortality is provided that includes trends over time and data on disparities by race/ethnicity, gender, and age, all of which is provided through the death certificate data file. These data are then followed by more detailed information derived from the CFRTs. Each chart and table cites the source of data. Data derived from death certificates are cited as Texas DSHS, VSU with the appropriate year(s) to follow. When CFRT data are used, the source reads Texas data from the National System (see Data and Limitations) with the appropriate year(s) to follow. Specific information about the circumstance of death were not available for all reviewed deaths, therefore the number of cases in which the information was available is noted within each table or chart.

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GENERALIZABILITY OF CFRT DATA

The number of deaths reviewed by cause varies. The proportion of reviewed deaths for one cause may be significantly higher than other causes. While the proportion of deaths reviewed may be relatively low, the demographic characteristics of these deaths are similar enough to the “unreviewed” cases to lend some degree of confidence that the specific circumstances of death derived from the reviews accurately reflect child fatalities in Texas (Table 2 through 4).

Table 2. Comparing Reviewed Deaths to All Deaths, All Causes of Mortality, 2005

2005 Child Population Estimates (%)

2005 Death Certificates (%)

2005 CFRT (%)

White 39.7 31.7 31.8 Black 12.5 20.9 22.2 Hispanic 44.4 45.4 44.4 Other 3.5 2.0 1.6 Male 51.1 58.2 59.0 Female 48.9 41.9 41.0 Infants 6.1 61.4 54.4 1-4 yrs 23.0 11.1 13.2 5-9 yrs 26.2 6.3 6.3 10-14 yrs 27.6 8.5 9.0 15-17 yrs 16.9 12.7 17.1

Source: Texas DSHS, VSU, 2005 Texas Data from the National System, 2005

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Table 3. Comparing Reviewed Deaths to All Deaths, Natural Causes of Mortality, 2005

2005 Death Certificates (%)

2005 CFRT (%)

White 29.4 30.6 Black 21.4 23.2 Hispanic 47.2 44.8 Other 2.0 1.5

Male 55.3 56.4 Female 44.7 43.6

Infants 77.9 79.0 1-4 yrs 7.1 7.2 5-9 yrs 4.5 4.9 10-14 yrs 6.1 5.0 15-17 yrs 4.4 5.0

Table 4. Comparing Reviewed Deaths to All Deaths, Injury Causes of Mortality, 2005

2005 Death Certificates (%)

2005 CFRT (%)

White 41.3 35.4 Black 14.6 20.0 Hispanic 41.9 42.9 Other 2.1 1.7

Male 66.3 62.6 Female 33.7 37.4

Infants 7.9 13.6 1-4 yrs 21.1 23.4 5-9 yrs 12.0 9.1 10-14 yrs 18.2 15.8 15-17 yrs 40.9 37.9

Source: Texas DSHS, VSU, 2005 Texas Data from the National System, 2005

Source: Texas DSHS, VSU, 2005 Texas Data from the National System, 2005

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Source: Texas DSHS, VSU, 1990-2005

Source: Texas DSHS, VSU, 1990-2005

AN OVERVIEW OF MORTALITY IN TEXAS

Every year more than 4,000 Texas children under the age of 18 years die. Over the course of time, the number and rate of child deaths have been substantially reduced. There were 4,407 deaths in 1990, a rate of 90.7 deaths per 100,000 children in the population. By the end of the decade, the rate had declined 26% (3,849 deaths, 66.8 deaths per 100,000 children in 1999). However, there has been little decline in the rate of child death during the first six years of the 21st century (Chart 3). This pattern of steady declines followed by a period of little to no change was also found when the data were stratified by gender and race/ethnicity. This pattern also was duplicated among each age group with the exception of children 15 to 17 years old among whom the rates continue to decline (Chart 4). Trends in mortality data by age, race/ethnicity, and gender can be found in Appendix F.

Chart 2. Trends in Child (0 through 17 years of age) Mortality, 1990 through 2005

Chart 3. Trends in Child (15 through 17 years of age) Mortality, 1990 through 2005

40

50

60

70

80

90

100

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

40

50

60

70

80

90

100

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Rate per 100,000

Rate per 100,000

33

Chart 4. Infant Mortality Rates by Race/Ethnicity, 2005

5.1

13.9

6.3

3.2

0

4

8

12

16

White Black Hispanic Other

Rate per

1,000 live births

Source: Texas DSHS, VSU, 2005

Source: Texas DSHS, VSU, 2005

Among children ages 17 years and less, the majority of deaths occur among infants. Over 61% of the 4,122 child deaths in 2005 were to children less than one year of age. Many infant deaths occur during the first 28 days of life (neonatal period) from causes that are often difficult to prevent, such as perinatal conditions, prematurity, and congenital malformations. Males account for 58% of all child deaths. The risk for males increases with age; three out of four adolescent deaths (15 to 17 years of age) were male. Black children are overrepresented among childhood deaths, particularly among the young. Black infant mortality rates are double those of other racial/ethnic groups (Chart 5). While the rate of deaths among Black children is greatest among 5 to 14 year olds, there are no differences by race among 15 to 17 year olds (Chart 6). Chart 5. Child (Ages 1 to 17 years) Mortality Rates by Race/Ethnicity and Age, 2005

25.6

19.6

51.0

25.3 25.328.5

51.1

31.5

13.0

19.0

50.5

12.09.0

13.3

24.5

16.9

0

10

20

30

40

50

60

1 to 4 years 5 to 9 years 10 to 14 years 15 to 17 years

White Black Hispanic Other

Rate per 100,000

34

There are significant geographic differences in child mortality throughout Texas. Texas is geographically diverse, encompassing seven of the United States’ 50 largest cities (Houston – 4, San Antonio – 7, Dallas – 9, Austin – 16, Fort Worth – 19, El Paso – 21, Arlington – 50) as well as areas in West Texas that are classified as frontier (Source: U.S. Census Bureau. www.census.gov. 1900–2005 population estimates). When analyzing child mortality patterns by geography, it is important to remember that a county with a relatively small population may have a high rate per 100,000 but a small number of deaths, while a large county may have a lower rate but significantly more deaths. Map 5 illustrates the geographic disparities in child mortality rates per 100,000 while Map 6 displays the number of child deaths per county. Of Texas’ 254 counties, 22 (8.7%) had child mortality rates in excess of 100 child deaths per 100,000 population. However, generally, the population in these counties is relatively sparse. The average county population among these 22 counties was 13,040 children under 18 years of age compared to the average county size of 24,560 children less than 18 years of age throughout Texas. The counties with the highest mortality rates (Kenedy, McMullen, Menard, and Roberts) each had an average of less than 10 deaths in 2005. However, the counties with the greatest numbers of deaths (Bexar, Tarrant, Dallas, and Harris) had mortality rates of 97.3 deaths per 100,000 or less. There were no deaths in 84 of the 254 counties in Texas.

Tarrant (439) Dallas (583)

Bexar (350)

Hidalgo (114) Nueces (109)

Travis (173)

Harris (904)

Map 5. Child Mortality Rates by County, 2005

Map 6. Number of Child Deaths by County, 2005

Rates per 100,000 children Number

49.9 or less

50.0 – 99.9

100.0 – 500.0

> 500.0

0.0

99 or less

100 – 200

201 - 600

> 600

0.0

Data source: Texas DSHS, VSU, 2005 Maps provided by Family Health Research and Program Development

El Paso (128)

35

UNDERSTANDING CAUSES OF DEATH All causes of mortality can be divided into natural causes and injuries (Figure 2). In this report, the only natural cause of death discussed is Sudden Infant Death Syndrome (SIDS). Injuries are further divided into unintentional and intentional injuries. The unintentional injuries presented here are drowning and motor vehicle crashes. The intentional injuries presented are homicide and suicide. Firearm deaths are presented separately because these deaths overlap with other causes of death and include both intentional and unintentional injuries.

Figure 2. Causes of Mortality Included in the 2005 CFRT Annual Report The number of deaths due to injury has declined 21% in the last five years, and there were 96 fewer natural deaths in 2005 compared to 2001. The leading cause of death changes with age, as injuries surpass natural causes after age 1 (Chart 7); of the 1,590 deaths among children 1-17 years of age, 49% were due to injuries.

Chart 6. Child Deaths by Cause and Age, 2005

77.2

29.341.1

29.5

12.39.5

6754.4

65.9

83.6

0

20

40

60

80

100

Infants 1-4 years 5-9 years 10-14 years 15-17 years

Natural Injury Unknown

%

Source: Texas DSHS, VSU 2005

36

NATURAL CAUSES OF DEATH

Sudden Infant Death Syndrome (SIDS) Sudden Infant Death Syndrome (SIDS) is a definition of exclusion and can only apply to an infant whose death is sudden and unexpected, and remains unexplained after the performance of an adequate postmortem investigation that includes:

• an autopsy, • investigation of the scene and circumstances of the death, and • exploration of the medical history of the infant and family.

Generally, but not always, the infant is found dead after having been put to sleep and exhibits no signs of having suffered. SIDS is the leading cause of infant death in the postneonatal period (death between 29 and 365 days of life). In 2005, over 73% of all SIDS deaths occurred between one and three months of age (Chart 8).

Chart 7. Age at Death among Infants who Died of SIDS, 2005

SIDS rates in 2005 are 44% lower than they were in 1990 (Chart 9). While SIDS rates have declined, it is important to note that complex factors may be influencing this decline. In an American Journal of Epidemiology article (Shapiro-Mendoza CK, Tomashek KM, Anderson RN, Wingo J. Recent national trends in sudden, unexpected infant deaths: more evidence

Source: Texas DSHS, VSU, 2005

8.9

21.0

24.8

18.7

10.8

6.5 5.6

1.4 1.40.0 0.5 0.5

0

5

10

15

20

25

30

<1 mon

th

1 mon

th

2 mon

ths

3 mon

ths

4 mon

ths

5 mon

ths

6 mon

ths

7 mon

ths

8 mon

ths

9 mon

ths

10 m

onths

11 m

onths

%

37

supporting a change in classification or reporting. 2006 Apr 15;163(8):762-9.), the authors noted that the decline in SIDS rates may not be reflective of an actual decline, but may be the result of medical examiners choosing other causes of death such as suffocation or undetermined.

Chart 8. SIDS Rates, 1990 through 2005

Consistent with national data, Black infants have the highest rate of SIDS (1.4 cases per 1,000), more than double the rate of Whites (0.56 per 1,000). Hispanics have the lowest SIDS rates in Texas with 0.41 cases per 1,000. SIDS rates among male infants (0.67 per 1,000) were higher than rates among female infants (0.44 per 1,000), which is also consistent with national trends. Through their reviews, local CFRTs identified whether behaviors that are known to prevent SIDS were being practiced (Chart 9). These behaviors included placing the child to sleep on his/her back, not exposing the child to environmental tobacco smoke (ETS), sleeping alone, and sleeping in a crib. Between 1999 and 2005, Texas CFRTs reviewed 839 SIDS deaths.

Chart 9. Proportion of Cases Where Behavior was Reported, 2005

0

0.2

0.4

0.6

0.8

1

1.2

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Source: Texas DSHS, VSU, 1990-2005

Rate per 1,000 infants

34.0

10.6

32.0

0

20

40

60

80

100

Placed on Back No Exposure to ETS Slept in Crib

Source: Texas data from National Systyem, 2005

%

38

UNINTENTIONAL INJURIES

Drowning The rate of deaths due to drowning has declined 43.3% from 3.0 deaths per 100,000 in 1990 to 1.7 deaths per 100,000 in 2005 (Chart 10). The number of drowning deaths and the rate of drowning deaths are each more than 45% higher among males than females (Table 5). Children ages one to four years had the highest number and rate of deaths due to drowning.

Chart 10. Number and Rate of Drowning Deaths, 1990 through 2005

Table 5. Sex, Race/Ethnicity, and Age of Children who Died of Drowning, 2005

Sex

Race/Ethnicity

Age

# Rate* # Rate* # Rate* Male 77 2.4 White 40 1.6 < 1 yr 10 2.6 Female 28 0.9 Black 24 3.1 1 – 4 53 3.7 Hispanic 39 1.4 5 – 9 16 1.0 Other 2 0.9 10 – 14 14 0.8 15 – 17 12 1.4 * per 100,000 N = 105

0

20

40

60

80

100

120

140

160

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

0

0.5

1

1.5

2

2.5

3

3.5

Number Rate

Source: Texas DSHS, VSU, 1990-2005

Source: Texas DSHS, VSU, 2005

# Rate per 100,000

39

Child Motor Vehicle Fatalities In 2005, child motor vehicle fatalities were responsible for 11% of all childhood fatalities in Texas. The highest number and rate of child motor vehicle fatalities occurred in 1996, which was followed by a steady decline in the rate of child motor vehicle fatalities (Chart 11). While the rate of child motor vehicle fatalities has declined by 30%, the overall number of child motor vehicle fatalities has decreased by only 22%.

Chart 11. Number and Rate of Child Motor Vehicle Fatalities, 1999 through 2005 More males than females under the age of 18 years die in motor vehicle crashes in Texas (Table 6). Children 15 through 17 years of age have the highest rates of motor vehicle fatalities. The next highest rate by age was among children less than one year of age.

0

100

200

300

400

500

600

700

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 20050

2

4

6

8

10

12

Number Rate

Source: Texas DSHS, VSU, 1990-2005

# Rate per 100,000

40

Table 6. Sex, Race/Ethnicity, and Age of Motor Vehicle Fatalities, 2005

Sex

Race/Ethnicity

Age

# Rate* # Rate* # Rate* Male 280 8.8 White 184 7.4 < 1 yr 21 5.5 Female 171 5.6 Black 47 6.1 1 – 4 78 5.4 Hispanic 209 7.6 5 – 9 65 4.0 Other 11 5.0 10 – 14 89 5.2 15 – 17 198 18.8 *per 100,000 N = 451 In half of all child motor vehicle fatalities, the fatality occurred to an occupant in a car. An additional 15% of fatalities were occupants in a pickup truck or van (Chart 12). Nearly one seventh of the children who died in motor vehicle fatalities were pedestrians. Among the 202 child motor vehicle fatalities reviewed in 2005, in 16.3% of the cases, a safety device was present but not used; in 10.9% of the cases, a safety device was needed but not present; and in 5.0% of the cases a safety device was present but not used correctly.

Chart 12. Classification of Child Motor Vehicle Fatalities, 2005

Pedestrian15%

Pedal Cyclist2%

Motorcyclist4%

Car Occupant50%

Pickup/Van15%

Other14%

Source: Texas DSHS, VSU, 2005

Source: Texas DSHS, VSU, 2005

41

INTENTIONAL INJURIES

Child Deaths from Homicide The rate and number of child deaths from homicide were highest in 1991 when there were 283 child deaths from homicide, a rate of 5.7 child deaths from homicide per 100,000 children (Chart 13). Between 1998 and 1995, there was a 38.8% decline in the rate of child deaths from homicide. In 2005, the rate of homicide among Texas children was 2.6 deaths per 100,000 and number of child deaths from homicide was 161.

Chart 13. Number and Rate of Child Deaths from Homicide, 1999 through 2005 There are gender and racial/ethnic disparities in the rate of child deaths from homicide in Texas. The rate of child deaths from homicide among males is 83.3% higher than among females (Table 7). The rate of child deaths from homicide among Blacks is 436.4% greater than the rate among Whites and 103.4% greater than the rate among Hispanics.

0

50

100

150

200

250

300

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 20050

1

2

3

4

5

6

Number Rate

Source: Texas DSHS, VSU, 1999-2005

# Rate per 100,000

42

Table 7. Sex, Race/Ethnicity, and Age of Child Deaths from Homicide, 2005

Sex

Race/Ethnicity

Age

# Rate* # Rate* # Rate* Male 105 2.3 White 28 1.1 < 1 yr 22 5.8 Female 56 1.8 Black 46 5.9 1 – 4 48 3.3 Hispanic 81 2.9 5 – 9 10 0.6 Other 6 2.7 10 – 14 26 1.5 15 – 17 55 5.2 *per 100,000 N = 161 Of the 161 child deaths from homicide in 2005, local CFRTs reviewed 115. Of those deaths, for cases in which the assailant was known, the most common place of child deaths from homicide was in the child’s own home and the parents were the most frequently identified assailants (Chart 14 and 15). In 73.9% of the cases, the assailant was not known.

Chart 14. Location of Child Deaths from Homicide, 2005

43.5

3.5

25.2 23.5

4.4

0

10

20

30

40

50

Home Otherresidence

Outside thehome

Other Unknown

%

Source: Texas DSHS, VSU, 2005

Source: Texas data from the National System, 2005

43

Chart 15. Assailant in Child Deaths from Homicide, 2005 Child Suicide In Texas in 2005, there were 88 suicides. The 2005 rate of 1.5 suicide deaths per 100,000 is 15.4% higher than the lowest rate reached between 1990 and 2005, 1.3 suicide deaths per 100,000 (Chart 16).

Chart 16. Suicide Death Rates, 1990 through 2005

12.2

0.9 1.7 4.4 2.6

73.9

0

10

20

30

40

50

60

70

80

Parent Otherrelative

Friend Parentparamour

Unknown tovictim

Unknown

%

Source: Texas data from National System, 2005

0

0.5

1

1.5

2

2.5

3

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Source: Texas DSHS, VSU, 1999-2005

Rate per

100,000

44

The rate of suicide deaths for males in 2005 was more than quadruple that of females (Table 8). Suicide is also more common among White and Hispanic children than Black children. There were fewer than 10 suicide deaths among Black children while the number exceeded 30 and 55 deaths among Hispanic children and White children, respectively. There were no suicides among children under the age of 10 years in 2005. The highest rate of death from suicide was found among children ages 15 to 17 years. Local CFRTs reviewed 61 of the suicides that occurred in 2005. More than 75% of child suicides occurred in the child’s home (Chart 17). Family discord, problems with one’s romantic partner, school problems, and death of a loved one were some of the possible contextual factors that may have contributed to the suicides based on the review of the case (Chart 18).

Table 8. Sex, Race/Ethnicity, and Age of Child Suicides, 2005

Sex

Race/Ethnicity

Age

# Rate* # Rate* # Rate* Male 78 2.5 White 56 2.3 < 1 yr 0 --- Female 18 0.6 Black 6 0.8 1 – 4 0 --- Hispanic 34 1.2 5 – 9 0 --- Other 0 --- 10 – 14 22 1.3 15 – 17 74 7.0 *per 100,000 N = 96

Chart 17. Location of Child Suicides, 2005

Source: Texas DSHS, VSU, 2005

75.4

9.814.6

0

10

20

30

40

50

60

70

80

Child's home Other residence Other

Source: Texas data from National System, 2005

%

45

Chart 18. Contextual Factors Surrounding Child Suicide, 2005

11.5

6.64.9

9.8

1.6

8.2

21.3

0

10

20

30

Family

Disc

ord

Alcohol/

Drug Use

Schoo

l Prob

lems

Problems w

/ Rom

antic

Partne

rs

Faile

d Acc

ompli

shment

Death o

f a Lov

ed O

neOther

Source: Texas data from National System, 2005

%

46

FIREARM DEATHS

Estimates suggest that there are over 250 million firearms in the United States (Jourdans F. Global study says civilians now hold 650 million small arms; about 270 million in U.S. August 10, 2007. www.ap.org). Given the prevalence of firearms and the likelihood that a child may encounter a firearm at home or when with a relative or neighbor, the safe storage of firearms is important to protect the lives of Texas’ children. Firearm deaths include four groups:

• unintentional deaths, • suicides firearm deaths, • homicides firearm deaths, and • firearm deaths of unknown intent.

During 2005, there were 119 firearm deaths in Texas. After a decline in the number of firearm deaths in 2000, the number of these deaths has remained constant. Between 1999 and 2005, the number of firearm deaths was lowest in 2004 (Chart 19). Between 1999 and 2005, firearm deaths were primarily associated with suicides and homicides (Chart 20).

Chart 19. Number of Firearm Deaths, 1999 through 2005

150

116128

115 118 112119

0

20

40

60

80

100

120

140

160

1999 2000 2001 2002 2003 2004 2005

#

Source: Texas DSHS, VSU, 1999 through 2005

47

Chart 20. Proportion of Firearm Deaths Attributed to Unintentional Death, Suicide, Homicide, and Unknown Intent, 1999 through 2005

The rate of firearm related deaths in 2005 was 343% higher among males than females (Table 9). Racial disparities were also found with rates of firearm related deaths among Blacks more than one and a half times the rates among Whites and Hispanics. Firearm deaths also have greater impact among 10- to 17-year-olds than among children less than 10 years of age. Children 10 to 17 years old accounted for 89.8% of all firearm related deaths.

Table 9. Sex, Race/Ethnicity, and Age of Child Firearm Deaths, 2005

Sex

Race/Ethnicity

Age

# Rate* # Rate* # Rate* Male 103 3.1 White 47 1.8 < 1 yr 1 0.3 Female 24 0.7 Black 27 3.0 1 – 4 7 0.4 Hispanic 52 1.8 5 – 9 5 0.3 Other 1 0.5 10 – 14 27 1.4 15 – 17 87 8.0 *per 100,000 N = 119

Unintentional3%

Suicide32%

Homicide54%

Unknown Intent11%

Source: Texas DSHS, VSU, 1999 through 2005

Source: Texas DSHS, VSU, 2005

48

Chart 21. Owner of Firearm in Firearm Related Deaths, 2005 Of the 119 firearm deaths in Texas in 2005, 77 were reviewed by local CFRTs. Injury prevention education messages targeting parents often focus on car seats, seat belts, life preservers, and bicycle helmets, but less on gun safety. To maximize gun safety and reduce the risk of unintentional injury or death, firearms should be locked and stored unloaded. In the 77 firearm deaths reviewed by local CFRTs, none of the firearms used were reported as stored and locked. In 10% of the cases reviewed, it was reported that the firearm was stored loaded. However, this information was unknown in nearly 90% of the reviews a similar proportion of unknown values were recorded for the owner of the firearm (Chart 21). The high number of unknown values for firearm related deaths is a by-product of the transition to the National Child Death Review Data Collection System (see Data and Limitations).

6.7 5.20.9

71.3

10.6

2.6 2.60

10

20

30

40

50

60

70

80

Parent Friend SomeoneElse in the

Home

Unknown Other Decedent OtherFamily

Source: Texas data from National System, 2005

%

49

Appendix A: SCFRT Committee

Members

Appendix A - 1

STATE CHILD FATALITY REVIEW TEAM COMMITTEE MEMBERS, 2007 Fouad Berrahou, PhD Title V & Family Health Director Texas Department of State Health Services 1100 W. 49th St. Austin, TX 78756 (512) 458-7111 x3207 fouad.berrahou@dshs.state.tx.us

Elsa Hinojosa, MEd

High School Principal Lehman High School, Hays CISD

1700 Lehman Rd. Kyle, TX 78640

(512) 268-8454 hinojosae@hayscisd.net

Kim Cheung, MD, PhD Pediatrician University of Texas Health Science Center at Houston Department of Pediatrics Child Protective Services Clinic 6300 Chimney Rock Houston, TX 77081 (713) 295-2579 kim.k.cheung@uth.tmc.edu

Judge Judy Schier Hobbs Justice of the Peace

Pct. 4, Williamson County P.O. Box 588

Taylor, TX 76574 (512) 365-8922

jhobbs@wilco.org

Trudy Deen Davis Volunteer Board Member Children’s Advocacy Centers of Texas, Inc. 4328 Sherman Blvd. Galveston, TX 77550 (409) 771-1772 trudydeen@comcast.net

Sgt. Sandra Hutchinson Sergeant, Violent Crimes, Domestic Violence

Emergency Response Team Austin Police Department

P.O. Box 689001 Austin, TX 78678

(512) 974-8511 sandra.hutchinson@ci.austin.tx.us

Sheriff Jack Ellett Panola County Sheriff’s Office 314 West Wellington Carthage, TX (903) 693-0333 jack.ellett@co.panola.tx.us

Joyce James, LMSW Assistant Commissioner, Child Protective Services

Department of Family and Protective Services MC: E-157

P.O. Box 149030 Austin, TX 78751-9030

(512) 438-3312 joyce.james@dfps.state.tx.us

Alice K. Gong, MD Neonatologist Professor of Pediatrics University of Texas Health Science Center at San Antonio MC 7812 7703 Floyd Curl Dr. San Antonio, TX 78229-3900 (210)567-5227 gong@uthscsa.edu

Eric Levy, MD, SCFRT Chair Pediatrician

Director, Pediatric Critical Care Medicine Associate Professor of Pediatrics

1301 Coulter, Suite 101 Amarillo, TX 79106

(806) 468-4326 elevymd@amaonline.com

Appendix A - 2

Geraldine R. Harris, MLA State Registrar, Texas Vital Statistics Department of State Health Services 1100 W. 49th St. Austin, TX 78756 (512) 458-7366 geraldine.harris@dshs.state.tx.us

Laurel Lindsey, JD Director of Investigations, Child Protective Services

Department of Family and Protective Services P.O. Box 149030

Austin, TX 78751-9030 (512) 438-4746

laurel.lindsey@dfps.state.tx.us

Donna Norris, MA Prevention Program Specialist Department of Family and Protective Services, Division of Prevention and Early Intervention P.O. Box 149030, MC Y-987 Austin, TX 78714-9030 (512) 929-6972 donna.norris@dfps.state.tx.us

Terry Pence

Traffic Safety Director Texas Department of Transportation

125 E. 11th St. Austin, TX 78701

(512) 416-3167 tpence@dot.state.tx.us

Denise Oncken, JD Assistant District Attorney Harris County Chief Child Abuse Division Harris County District Attorney’s Office 1201 Franklin, Suite 600 Houston, TX 77002 (713) 755-5546 oncken_denise@dao.hctx.net

Charles M. Skaggs, MA Executive Director of Juvenile Services

Williamson County Juvenile Services Department 1821 South Inner Loop

Georgetown, TX 78626 (512) 943-3216

charlyskaggs@wilco.org

Juan M. Parra, MD, MPH Pediatrician Associate Professor and Interim Division Head of General Pediatrics University of Texas Health Science Center at San Antonio Medical School 7703 Floyd Curl Dr. Mail Code 7808 San Antonio, TX 78229-3900 (210) 562-5344 PARRAJ@uthscsa.edu

Lt. Steven A. TellezLieutenant

Texas Department of Public Safety6502 S. New Braunfels

San Antonio, Texas 78223(210) 531-2202

Steven.Tellez@txdps.state.tx.us

Elizabeth Peacock, MD Medical Examiner Bexar County Medical Examiner’s Office 7337 Louis Pasteur Dr. San Antonio, TX 78229-4565 (210) 335-4000 epeacock@bexar.org

Raymond H.C. Teske, Jr., PhD Professor, College of Criminal Justice

Sam Houston State University 304 Elkins Lake

Hunstville, TX 77340 (936) 295-6274

rteske@suddenlink.net

Appendix A - 3

Appendix B: Active Local Child

Fatality Review Teams, 2007

Appendix B - 1

TEXAS LOCAL CHILD FATALITY REVIEW TEAMS, 2007 Name Service Area Presiding Officer Coordinator

Bastrop Co. CFRT

Bastrop County

Cheryl Koch, ED Children’s Advocacy Center of Bastrop 1002 Chestnut St. P.O. Box 1098 Bastrop, TX 78602 (512) 321-6161 cherylcacbastrop@austin.rr.com

Mindy Graber Children’s Advocacy Center of Bastrop 1002 Chestnut St. P.O. Box 1098 Bastrop, TX 78602 (512) 321-6161 mindycacbastrop@austin.rr.com

Bexar Co. CFRT Bexar County

Vickie Ernst, Associate Director ChildSafe 7130 West US Hwy. 90 San Antonio, TX 78227-3515 (210) 675-9000 vickiee@childsafe-sa.org Laurie Charles, RN, SANE-A, CA/CPSANE SANE Program Coordinator 333 N. Santa Rosa San Antonio, TX 78207 (210) 704-3330 laurie.charles@christushealth.org

Same as Co-Presiding Officers

Brazos Co. CFRT Brazos County Christopher C. Kirk, Sheriff

Brazos County Office of the Sheriff 300 E. 26th St., Suite 105 Bryan, TX 77803-5359 (979) 361-4150 chriskirk@highsheriff.com

Brenda Putz, Trauma Coordinator St Joseph’s Regional Health Center 2801 Franciscan Dr. Bryan, TX 77802 (979)776-4917 bputz@mail.st-joseph.org

Burleson Co. CFRT

Burleson County

Tiffany Graves Burleson County Sheriff’s Dept. Caldwell, TX (979)567-4343 tgraves@burlesoncounty.org

Pam Stetz, Social Worker Burleson St. Joseph Health Center 1101 Woodson Caldwell, TX 77836 (979)567-3245 pstetz@mail.st-joseph.org

Cameron/Willacy Counties CFRT

Cameron & Willacy Counties

Stanley I. Fisch, MD Harlingen Pediatrics Associates 321 South 21st Street Harlingen, TX 78550 (956) 425-8761 sfishch@rgv.rr.com

Same as Presiding Officer

Appendix B - 2

Name Service Area Presiding Officer Coordinator

Central Texas CFRT

Bell, Coryell, Falls, Hamilton & Milam Counties

Michelle Farrell, ED Children’s Advocacy Center of Central Texas 402 N. Main P.O. Box 145 Belton, TX 76513 (254) 939-2946 x1 caccted@hot.rr.com

Same as Presiding Officer

Collin Co. CFRT Collin County

Susan Etheridge, ED Collin County Children’s Advocacy Center 2205 Los Rios Blvd. Plano, TX 75074 (972) 633-6601 setheridge@cacplano.org

Caralee Gurney Collin County Children’s Advocacy Center 2205 Los Rios Blvd. Plano, TX 75074 (972) 633-6601 cgurney@cacplano.org

Concho Valley CFRT

Coke, Concho, Crockett, Irion, Kimble, Menard, McCulloch, Regan, Runnels, Schleicher, Sterling, Sutton & Tom Green Counties

Judge Eddie Howard, JP Tom Green County, Precinct 4 124 W. Beauregard San Angelo, TX 76903 (325) 659-6424 eddie.howard@co.tom-green.tx.us

Debra R. Brown, Executive Director Hope House Children’s Advocacy Center of Tom Green County 317 Koberlin P.O. Box 5195 San Angelo, TX 76902 (325) 653-4673 drbrown@suddenlinkmail.com

Dallas Co. CFRT Dallas County

Carrie Nie Injury Prevention Center of Greater Dallas 5000 Harry Hines P.O. Box 36067 Dallas, TX 75235 (214) 590-4461 cnie@parknet.pmh.org

Amy McSpadden Injury Prevention Center of Greater Dallas 5000 Harry Hines P.O. Box 36067 Dallas, TX 75235 (214) 590-4461 AMCSP1@parknet.pmh.org

Ellis Co. CFRT Ellis County

Marlena Pendley, Investigator Ellis Co. District Attorney’s Office P.O. Box 2838 Waxahachie, TX 75168-2838 (972) 937-1870 mar9763@aol.com

Same as Presiding Officer

El Paso Co. CFRT El Paso County

Jaime Esparza El Paso District Attorney’s Office 500 E. San Antonio Ave. Suite 201 El Paso, TX 79901 (915) 546-2059 jesparza@epcounty.com

Donna Welch, Paralegal El Paso District Attorney’s Office 500 E. San Antonio Avenue, Suite 201 El Paso, TX 79901 (915) 546-2059 ext 3701 dwelch@epcounty.com

Appendix B - 3

Name Service Area Presiding Officer Coordinator

Galveston Co. CFRT

Galveston County

Louise Pound, Case Manager Advocacy Center for Children of Galveston County 5710 Avenue S1/2 Galveston, TX 77551 (409) 741-6000 lpound@sbcglobal.net

Same as Presiding Officer

Grayson Co. CFRT

Grayson County

Martha Nuckols Children’s Advocacy Center of Grayson County 910 Cottonwood Sherman, TX 75090 (903)957-0440 mnuckols@cacgc.org

Same as Presiding Officer

Houston/Harris Co. CFRT

Harris County

Cindy Kilborn Chief Epidemiologist Harris County Public Health & Environmental Services 2223 West Loop South Houston, TX 77027 (713) 439-6160 ckilborn@hcphes.org

Stephani Adams Houston/Harris Co. CFRT Coordinator Harris Co. Public Health & Environmental Services 2223 West Loop South Houston, TX 77027 (713) 439-6137 sadams@hcphes.org

Hunt Co. CFRT Hunt County

Bret Freeman, RN, CEN Trauma Coordinator Presbyterian Hospital of Greenville 4215 Joe Ramsey Blvd. Greenville, TX 75401 (903) 408-1412 bfreeman@hmhd.org

Same as Presiding Officer

Jefferson Co. CFRT

Jefferson County

Marion Tanner, ED The Garth House/Mickey Mehaffy Children’s Advocacy Program 1895 McFaddin Beaumont, TX 77701 (409) 838-9084 mtanner@garthhouse.net

Janet Morris The Garth House/Mickey Mehaffy Children’s Advocacy Program 1895 McFaddin Beaumont, TX 77701 (409) 838-9084 jmorris@garthhouse.net

Madison/Leon Counties CFRT

Madison & Leon Counties

Julia Jarrell Trauma Coordinator Madison St. Joseph Health Center Madisonville, TX jjarrell@mail.st-joseph.org

Pam Stetz, Social Worker Burleson St. Joseph Health Center 1101 Woodson Caldwell, TX 77836 (979)567-3245 pstetz@mail.st-joseph.org

McLennan Co. CFRT

McLennan County

Kerry Burkley, Program Director Advocacy Center for Crime Victims and Children 2323 Columbus Ave. Waco, TX 76701 (254) 752-9330 ext. 101 kburkley@advocacycntr.org

Same as Presiding Officer

Appendix B - 4

Name Service Area Presiding Officer Coordinator Nacogdoches Co. CFRT

Nacogdoches County

Lisa King Child Welfare Board 818 Park St. Nacogdoches, TX 75961 (936) 560-2338 Lking19@hotmail.com

Same as Presiding Officer

Orange Co. CFRT

Orange County

Kim Hanks, Interview Specialist Garth House Mickey Mehaffy Children’s Advocacy Program 1895 McFaddin Beaumont, TX 77701 (409) 838-9084 khanks@garthhouse.net

Same as Presiding Officer

Panhandle CFRT Armstrong,

Briscoe, Carson, Castro, Childress, Collingsworth, Dallam, Deaf Smith, Donley, Gray, Hall, Hansford, Hartley, Hemphill, Hutchinson, Lipscomb, Moore, Ochiltree, Oldham, Parmer, Potter, Randall, Roberts, Sherman, Swisher & Wheeler Counties

Gil Farren Victim/Witness Coordinator Randall County Sheriff’s Office 9100 S. Georgia Amarillo, TX 79118 (806) 468-5790 (sheriff’s office) (806) 468-5570 (DA’s office) (806) 670-2494 (cell) gfarren@randallcounty.org Melissa Blackburn Youth Center of the High Plains Randall County Juvenile Probation Dept. 9300 S. Georgia Amarillo, TX 79118 (806) 468-5704 melissablackburn@rcjp.com

Same as Presiding Co-officers

Smith Co. CFRT Smith County

Jason Gillentine Department of Family & Protective Services 3303 Mineola Hwy. Tyler, TX 75702 (903) 533-4127 (903) 780-5681 (cell) jason.gillentine@dfps.state.tx.us Sue Hinson, RN, SANE Trinity Mother Frances Health System 800 East Dawson Tyler, TX 75701 (903) 531-4214

Same as Presiding Co-officers

Appendix B - 5

Name Service Area Presiding Officer Coordinator

South Plains CFRT

Bailey, Borden, Cochran, Cottle, Crosby, Dawson, Dickens, Floyd, Gaines, Garza, Hale, Hockley, Kent, King, Lamb, Lubbock, Lynn, Motley, Scurry, Stonewall, Terry & Yoakum Counties

Patti Salazar, SANE C.A.R.E. Center Texas Tech University Health Science Center Department of Pediatrics 6630 Quaker Avenue, Suite 202 Lubbock, TX 79413 (806) 743-7770 patricia.salazar@ttuhsc.edu

Same as Presiding Officer

Tarrant Co. CFRT Tarrant, Denton

& Parker Counties

Michael V. Floyd Senior Forensic Investigator Tarrant County Medical Examiner’s Office 200 Feliks Gwozdz Place Fort Worth, TX 76104-4919 (817) 920-5700 ext 120 mfloyd@tarrantcounty.com

Same as Presiding Officer

Travis Co. CFRT Travis County

Dayna Blazey, Assistant District Attorney Office of the District Attorney P.O. Box 1748 Austin, TX 78767 (512) 974-6830 dayna.blazey@ci.austin.tx.us

Sandra Martin, ED Center for Child Protection 1100 E. 32nd St. Austin, TX 75722 (512) 472-1164 smartin@centerforchildprotection.org

Tri-County CFRT Harrison,

Panola & Rusk Counties

Sheriff Jack Ellett Panola Co. Sheriff’s Department 314 W. Wellington St. Carthage, TX 75633 (903) 693-0333 jack.ellett@co.panola.tx.us

Sarah Fields, Sergeant Panola County Sheriff’s Department 314 W. Wellington St. Carthage, TX 75633 (903) 693-0333 sgtfields@hotmail.com

Victoria Co. CFRT

Victoria County

Adelaida Resendez, MD Pediatrician 110 Medical Dr. #103 Victoria, TX 77904-3101 (361) 572-0033

Gilda Miller, RNC, Nurse Manager Citizens Medical Center 2701 Hospital Drive Victoria, TX 77901-5749 (361) 574-1777 gmiller@cmcvtx.org

Walker Co. CFRT Walker County

Raymond Teske, Jr., Ph. D. 304 Elkins Lake Huntsville, TX 77340 (936) 295-6274 rteske@suddenlink.net

Jane Teske 304 Elkins Lake Huntsville, TX 77340 (946) 295-6274

Appendix B - 6

Name Service Area Presiding Officer Coordinator

Washington/ Grimes Counties CFRT

Washington & Grimes Counties

Marsha Doebler Trinity Wellness Center 2111 South Day St. Brenham, TX (979) 830-5017 mdoebler@trinitymed.org

Same as Presiding Officer

Webb Co. CFRT Webb & Zapata

Counties

Guadalupe Martinez, Forensic Interviewer Children’s Advocacy Center of Webb County 1302 Cedar Avenue Laredo, TX 78040 (956) 712-1840 fi@caclaredo.org

Same as Presiding Officer

Williamson Co. CFRT

Williamson County

Judge Judy Schier Hobbs Justice of the Peace, Pct. 4 211 W. 6th St. Taylor, TX 76574-3539 jhobbs@wilco.org

Linda Kaderka Office of the Justice of the Peace, Pct. 4 211 W. 6th St. Taylor, TX (512) 352-6978 lkaderka@wilco.org

Appendix C - 0

Appendix C: Texas Family Code

Appendix C - 1

TEXAS FAMILY CODE

CHAPTER 264 SUBCHAPTER F. CHILD FATALITY REVIEW & INVESTIGATION

§ 264.501. DEFINITIONS. In this subchapter: (1) "Autopsy" and "inquest" have the meanings assigned by Article 49.01, Code of Criminal Procedure. (2) "Bureau of vital statistics" means the bureau of vital statistics of the Texas Department of Health. (3) "Child" means a person younger than 18 years of age. (4) "Committee" means the child fatality review team committee. (5) "Department" means the Department of Protective and Regulatory Services. (6) "Health care provider" means any health care practitioner or facility that provides medical evaluation or treatment, including dental and mental health evaluation or treatment. (7) "Meeting" means an in-person meeting or a meeting held by telephone or other electronic medium. (8) "Preventable death" means a death that may have been prevented by reasonable medical, social, legal, psychological, or educational intervention. The term includes the death of a child from: (A) intentional or unintentional injuries; (B) medical neglect; (C) lack of access to medical care; (D) neglect and reckless conduct, including failure to supervise and failure to seek medical care; and (E) premature birth associated with any factor described by Paragraphs (A) through (D). (9) "Review" means a reexamination of information regarding a deceased child from relevant agencies, professionals, and health care providers. (10) "Review team" means a child fatality review team established under this subchapter. (11) "Unexpected death" includes a death of a child that, before investigation: (A) appears to have occurred without anticipation or forewarning; and (B) was caused by trauma, suspicious or obscure circumstances, sudden infant death syndrome, abuse or neglect, or an unknown cause. Added by Acts 1995, 74th Leg., ch. 255, § 2, eff. Sept. 1, 1995; Acts 1995, 74th Leg., ch. 878, § 1, eff. Sept. 1, 1995. Amended by Acts 2001, 77th Leg., ch. 957, § 2, eff. Sept. 1, 2001. § 264.502. COMMITTEE. (a) The child fatality review team committee is composed of: (1) a person appointed by and representing the state registrar of vital statistics; (2) a person appointed by and representing the

Appendix C - 2

commissioner of the department; (3) a person appointed by and representing the Title V director of the Department of State Health Services; and (4) individuals selected under Subsection (b). (b) The members of the committee who serve under Subsections (a)(1) through (3) shall select the following additional committee members: (1) a criminal prosecutor involved in prosecuting crimes against children; (2) a sheriff; (3) a justice of the peace; (4) a medical examiner; (5) a police chief; (6) a pediatrician experienced in diagnosing and treating child abuse and neglect; (7) a child educator; (8) a child mental health provider; (9) a public health professional; (10) a child protective services specialist; (11) a sudden infant death syndrome family service provider; (12) a neonatologist; (13) a child advocate; (14) a chief juvenile probation officer; (15) a child abuse prevention specialist; (16) a representative of the Department of Public Safety; and (17) a representative of the Texas Department of Transportation. (c) Members of the committee selected under Subsection (b) serve three-year terms with the terms of five or six members, as appropriate, expiring February 1 each year. (d) Members selected under Subsection (b) must reflect the geographical, cultural, racial, and ethnic diversity of the state. (e) An appointment to a vacancy on the committee shall be made in the same manner as the original appointment. A member is eligible for reappointment. (f) Members of the committee shall select a presiding officer from the members of the committee. (g) The presiding officer of the committee shall call the meetings of the committee, which shall be held at least quarterly. (h) A member of the committee is not entitled to compensation for serving on the committee but is entitled to reimbursement for the member's travel expenses as provided in the General Appropriations Act. Reimbursement under this subsection for a person serving on the committee under Subsection (a)(2) shall be paid from funds appropriated to the department. Reimbursement for other persons serving on the committee shall be paid from funds appropriated to the Department of State Health Services. Added by Acts 1995, 74th Leg., ch. 255, § 2, eff. Sept. 1, 1995; Acts 1995, 74th Leg., ch. 878, § 1, eff. Sept. 1, 1995. Amended by Acts 2001, 77th Leg., ch. 957, § 3, eff. Sept. 1, 2001. Amended by: Acts 2005, 79th Leg., Ch. 268, § 1.56, eff. September 1, 2005. Acts 2007, 80th Leg., R.S., Ch. 396, § 1, eff. September 1, 2007.

Appendix C - 3

§ 264.503. PURPOSE AND DUTIES OF COMMITTEE AND SPECIFIED STATE AGENCIES. (a) The purpose of the committee is to: (1) develop an understanding of the causes and incidence of child deaths in this state; (2) identify procedures within the agencies represented on the committee to reduce the number of preventable child deaths; and (3) promote public awareness and make recommendations to the governor and the legislature for changes in law, policy, and practice to reduce the number of preventable child deaths. (b) To ensure that the committee achieves its purpose, the department and the Department of State Health Services shall perform the duties specified by this section. (c) The department shall work cooperatively with: (1) the Department of State Health Services; (2) the committee; and (3) individual child fatality review teams. (d) The Department of State Health Services shall: (1) recognize the creation and participation of review teams; (2) promote and coordinate training to assist the review teams in carrying out their duties; (3) assist the committee in developing model protocols for: (A) the reporting and investigating of child fatalities for law enforcement agencies, child protective services, justices of the peace and medical examiners, and other professionals involved in the investigations of child deaths; (B) the collection of data regarding child deaths; and (C) the operation of the review teams; (4) develop and implement procedures necessary for the operation of the committee; and (5) promote education of the public regarding the incidence and causes of child deaths, the public role in preventing child deaths, and specific steps the public can undertake to prevent child deaths. (d-1) The committee shall enlist the support and assistance of civic, philanthropic, and public service organizations in the performance of the duties imposed under Subsection (d). (e) In addition to the duties under Subsection (d), the Department of State Health Services shall: (1) collect data under this subchapter and coordinate the collection of data under this subchapter with other data collection activities; and (2) perform annual statistical studies of the incidence and causes of child fatalities using the data collected under this subchapter. (f) The committee shall issue a report for each preventable child death. The report must include findings related to the child's death, recommendations on how to prevent similar deaths, and details surrounding the department's involvement with the child prior to the child's death. Not later than April 1 of each year, the committee shall publish a compilation of the reports published under this subsection during the year, submit a copy of the compilation to the governor, lieutenant governor, speaker of the house of representatives, and department, and make the compilation

Appendix C - 4

available to the public. Not later than October 1 of each year, the department shall submit a written response on the compilation from the previous year to the committee, governor, lieutenant governor, and speaker of the house of representatives describing which of the committee's recommendations regarding the operation of the child protective services system the department will implement and the methods of implementation. (g) The committee shall perform the functions and duties required of a citizen review panel under 42 U.S.C. Section 5106a(c)(4)(A). Added by Acts 1995, 74th Leg., ch. 255, § 2, eff. Sept. 1, 1995; Acts 1995, 74th Leg., ch. 878, § 1, eff. Sept. 1, 1995. Amended by Acts 2001, 77th Leg., ch. 957, § 4, eff. Sept. 1, 2001. Amended by: Acts 2005, 79th Leg., Ch. 268, § 1.57, eff. September 1, 2005. Acts 2007, 80th Leg., R.S., Ch. 396, § 2, eff. September 1, 2007. § 264.504. MEETINGS OF COMMITTEE. (a) Except as provided by Subsections (b), (c), and (d), meetings of the committee are subject to the open meetings law, Chapter 551, Government Code, as if the committee were a governmental body under that chapter. (b) Any portion of a meeting of the committee during which the committee discusses an individual child's death is closed to the public and is not subject to the open meetings law, Chapter 551, Government Code. (c) Information identifying a deceased child, a member of the child's family, a guardian or caretaker of the child, or an alleged or suspected perpetrator of abuse or neglect of the child may not be disclosed during a public meeting. On a majority vote of the committee members, the members shall remove from the committee any member who discloses information described by this subsection in a public meeting. (d) Information regarding the involvement of a state or local agency with the deceased child or another person described by Subsection (c) may not be disclosed during a public meeting. (e) The committee may conduct an open or closed meeting by telephone conference call or other electronic medium. A meeting held under this subsection is subject to the notice requirements applicable to other meetings. The notice of the meeting must specify as the location of the meeting the location where meetings of the committee are usually held. Each part of the meeting by telephone conference call that is required to be open to the public shall be audible to the public at the location specified in the notice of the meeting as the location of the meeting and shall be tape-recorded. The tape recording shall be made available to the public. (f) This section does not prohibit the committee from requesting the attendance at a closed meeting of a person who is not a member of the committee and who has information regarding a deceased child. Added by Acts 1995, 74th Leg., ch. 255, § 2, eff. Sept. 1, 1995; Acts 1995, 74th Leg., ch. 878, § 1, eff. Sept. 1, 1995.

Appendix C - 5

Amended by: Acts 2005, 79th Leg., Ch. 268, § 1.58, eff. September 1, 2005. § 264.505. ESTABLISHMENT OF REVIEW TEAM. (a) A multidisciplinary and multiagency child fatality review team may be established for a county to review child deaths in that county. A review team for a county with a population of less than 50,000 may join with an adjacent county or counties to establish a combined review team. (b) Any person who may be a member of a review team under Subsection (c) may initiate the establishment of a review team and call the first organizational meeting of the team. (c) A review team may include: (1) a criminal prosecutor involved in prosecuting crimes against children; (2) a sheriff; (3) a justice of the peace or medical examiner; (4) a police chief; (5) a pediatrician experienced in diagnosing and treating child abuse and neglect; (6) a child educator; (7) a child mental health provider; (8) a public health professional; (9) a child protective services specialist; (10) a sudden infant death syndrome family service provider; (11) a neonatologist; (12) a child advocate; (13) a chief juvenile probation officer; and (14) a child abuse prevention specialist. (d) Members of a review team may select additional team members according to community resources and needs. (e) A review team shall select a presiding officer from its members. Added by Acts 1995, 74th Leg., ch. 255, § 2, eff. Sept. 1, 1995; Acts 1995, 74th Leg., ch. 878, § 1, eff. Sept. 1, 1995. Amended by: Acts 2005, 79th Leg., Ch. 268, § 1.59, eff. September 1, 2005. § 264.506. PURPOSE AND DUTIES OF REVIEW TEAM. (a) The purpose of a review team is to decrease the incidence of preventable child deaths by: (1) providing assistance, direction, and coordination to investigations of child deaths; (2) promoting cooperation, communication, and coordination among agencies involved in responding to child fatalities; (3) developing an understanding of the causes and incidence of child deaths in the county or counties in which the review team is located; (4) recommending changes to agencies, through the agency's representative member, that will reduce the number of

Appendix C - 6

preventable child deaths; and (5) advising the committee on changes to law, policy, or practice that will assist the team and the agencies represented on the team in fulfilling their duties. (b) To achieve its purpose, a review team shall: (1) adapt and implement, according to local needs and resources, the model protocols developed by the department and the committee; (2) meet on a regular basis to review child fatality cases and recommend methods to improve coordination of services and investigations between agencies that are represented on the team; (3) collect and maintain data as required by the committee; and (4) submit to the bureau of vital statistics data reports on deaths reviewed as specified by the committee. (c) A review team shall initiate prevention measures as indicated by the review team's findings. Added by Acts 1995, 74th Leg., ch. 255, § 2, eff. Sept. 1, 1995; Acts 1995, 74th Leg., ch. 878, § 1, eff. Sept. 1, 1995. § 264.507. DUTIES OF PRESIDING OFFICER. The presiding officer of a review team shall: (1) send notices to the review team members of a meeting to review a child fatality; (2) provide a list to the review team members of each child fatality to be reviewed at the meeting; (3) submit data reports to the bureau of vital statistics not later than the 30th day after the date on which the review took place; and (4) ensure that the review team operates according to the protocols developed by the department and the committee, as adapted by the review team. Added by Acts 1995, 74th Leg., ch. 255, § 2, eff. Sept. 1, 1995; Acts 1995, 74th Leg., ch. 878, § 1, eff. Sept. 1, 1995. § 264.508. REVIEW PROCEDURE. (a) The review team of the county in which the injury, illness, or event that was the cause of the death of the child occurred, as stated on the child's death certificate, shall review the death. (b) On receipt of the list of child fatalities under Section 264.507, each review team member shall review the member's records and the records of the member's agency for information regarding each listed child. Added by Acts 1995, 74th Leg., ch. 255, § 2, eff. Sept. 1, 1995; Acts 1995, 74th Leg., ch. 878, § 1, eff. Sept. 1, 1995. § 264.509. ACCESS TO INFORMATION. (a) A review team may request information and records regarding a deceased child as necessary to carry out the review team's purpose and duties. Records and information that may be requested under this section include: (1) medical, dental, and mental health care information; and

Appendix C - 7

(2) information and records maintained by any state or local government agency, including: (A) a birth certificate; (B) law enforcement investigative data; (C) medical examiner investigative data; (D) juvenile court records; (E) parole and probation information and records; and (F) child protective services information and records. (b) On request of the presiding officer of a review team, the custodian of the relevant information and records relating to a deceased child shall provide those records to the review team at no cost to the review team. (c) This subsection does not authorize the release of the original or copies of the mental health or medical records of any member of the child's family or the guardian or caretaker of the child or an alleged or suspected perpetrator of abuse or neglect of the child which are in the possession of any state or local government agency as provided in Subsection (a)(2). Information relating to the mental health or medical condition of a member of of the child's family or the guardian or caretaker of the child or the alleged or suspected perpetrator of abuse or neglect of the child acquired as part of an investigation by a state or local government agency as provided in Subsection (a)(2) may be provided to the review team. Added by Acts 1995, 74th Leg., ch. 255, § 2, eff. Sept. 1, 1995; Acts 1995, 74th Leg., ch. 878, § 1, eff. Sept. 1, 1995. Amended by: Acts 2005, 79th Leg., Ch. 268, § 1.60, eff. September 1, 2005. § 264.510. MEETING OF REVIEW TEAM. (a) A meeting of a review team is closed to the public and not subject to the open meetings law, Chapter 551, Government Code. (b) This section does not prohibit a review team from requesting the attendance at a closed meeting of a person who is not a member of the review team and who has information regarding a deceased child. (c) Except as necessary to carry out a review team's purpose and duties, members of a review team and persons attending a review team meeting may not disclose what occurred at the meeting. (d) A member of a review team participating in the review of a child death is immune from civil or criminal liability arising from information presented in or opinions formed as a result of a meeting. Added by Acts 1995, 74th Leg., ch. 255, § 2, eff. Sept. 1, 1995; Acts 1995, 74th Leg., ch. 878, § 1, eff. Sept. 1, 1995. § 264.511. USE OF INFORMATION AND RECORDS; CONFIDENTIALITY. (a) Information and records acquired by the committee or by a review team in the exercise of its purpose and duties under this subchapter are confidential and exempt from disclosure under the open records law, Chapter 552, Government

Appendix C - 8

Code, and may only be disclosed as necessary to carry out the committee's or review team's purpose and duties. (b) A report of the committee or of a review team or a statistical compilation of data reports is a public record subject to the open records law, Chapter 552, Government Code, as if the committee or review team were a governmental body under that chapter, if the report or statistical compilation does not contain any information that would permit the identification of an individual. (c) A member of a review team may not disclose any information that is confidential under this section. (d) Information, documents, and records of the committee or of a review team that are confidential under this section are not subject to subpoena or discovery and may not be introduced into evidence in any civil or criminal proceeding, except that information, documents, and records otherwise available from other sources are not immune from subpoena, discovery, or introduction into evidence solely because they were presented during proceedings of the committee or a review team or are maintained by the committee or a review team. Added by Acts 1995, 74th Leg., ch. 255, § 2, eff. Sept. 1, 1995; Acts 1995, 74th Leg., ch. 878, § 1, eff. Sept. 1, 1995. § 264.512. GOVERNMENTAL UNITS. The committee and a review team are governmental units for purposes of Chapter 101, Civil Practice and Remedies Code. A review team is a unit of local government under that chapter. Added by Acts 1995, 74th Leg., ch. 255, § 2, eff. Sept. 1, 1995; Acts 1995, 74th Leg., ch. 878, § 1, eff. Sept. 1, 1995. § 264.513. REPORT OF DEATH OF CHILD. (a) A person who knows of the death of a child younger than six years of age shall immediately report the death to the medical examiner of the county in which the death occurs or, if the death occurs in a county that does not have a medical examiner's office or that is not part of a medical examiner's district, to a justice of the peace in that county. (b) The requirement of this section is in addition to any other reporting requirement imposed by law, including any requirement that a person report child abuse or neglect under this code. (c) A person is not required to report a death under this section that is the result of a motor vehicle accident. This subsection does not affect a duty imposed by another law to report a death that is the result of a motor vehicle accident. Added by Acts 1995, 74th Leg., ch. 255, § 2, eff. Sept. 1, 1995; Acts 1995, 74th Leg., ch. 878, § 1, eff. Sept. 1, 1995. § 264.514. PROCEDURE IN THE EVENT OF REPORTABLE DEATH. (a) A medical examiner or justice of the peace notified of a death of a child under Section 264.513 shall hold an inquest under Chapter 49, Code of Criminal Procedure, to determine whether the death is unexpected or the result of abuse or neglect. An inquest is not

Appendix C - 9

required under this subchapter if the child's death is expected and is due to a congenital or neoplastic disease. A death caused by an infectious disease may be considered an expected death if: (1) the disease was not acquired as a result of trauma or poisoning; (2) the infectious organism is identified using standard medical procedures; and (3) the death is not reportable to the Texas Department of Health under Chapter 81, Health and Safety Code. (b) The medical examiner or justice of the peace shall immediately notify an appropriate local law enforcement agency if the medical examiner or justice of the peace determines that the death is unexpected or the result of abuse or neglect, and that agency shall investigate the child's death. (c) In this section, the terms "abuse" and "neglect" have the meaning assigned those terms by Section 261.001. Added by Acts 1995, 74th Leg., ch. 255, § 2, eff. Sept. 1, 1995; Acts 1995, 74th Leg., ch. 878, § 1, eff. Sept. 1, 1995. Amended by Acts 1997, 75th Leg., ch. 1022, § 95, eff. Sept. 1, 1997; Acts 1997, 75th Leg., ch. 1301, § 2, eff. Sept. 1, 1997; Acts 1999, 76th Leg., ch. 785, § 3, eff. Sept. 1, 1999. § 264.515. INVESTIGATION. (a) The investigation required by Section 264.514 must include: (1) an autopsy, unless an autopsy was conducted as part of the inquest; (2) an inquiry into the circumstances of the death, including an investigation of the scene of the death and interviews with the parents of the child, any guardian or caretaker of the child, and the person who reported the child's death; and (3) a review of relevant information regarding the child from an agency, professional, or health care provider. (b) The review required by Subsection (a)(3) must include a review of any applicable medical record, child protective services record, record maintained by an emergency medical services provider, and law enforcement report. (c) The committee shall develop a protocol relating to investigation of an unexpected death of a child under this section. In developing the protocol, the committee shall consult with individuals and organizations that have knowledge and experience in the issues of child abuse and child deaths. Added by Acts 1995, 74th Leg., ch. 255, § 2, eff. Sept. 1, 1995; Acts 1995, 74th Leg., ch. 878, § 1, eff. Sept. 1, 1995.

Appendix D - 1

Appendix D: How to Start a Child

Fatality Review Team In Your Community

Appendix D - 1

HOW TO START A CHILD FATALITY REVIEW TEAM IN YOUR COMMUNITY

1. Anyone with a potential role as a member of a Child Fatality Review Team as defined by the legislation (see

Appendix C) may convene a community meeting to discuss the child death review process, CFRT responsibilities and how the community can benefit from reviewing child deaths. The Texas Family Code states that a CFRT may include the following members (or their designees):

a. criminal prosecutor involved in the prosecution of crimes against children; b. sheriff; c. justice of the peace or medical examiner; d. police chief; e. pediatrician experienced in diagnosing and treating child abuse and neglect; f. child educator; g. child mental health provider; h. public health professional; i. child protective services specialist; j. Sudden Infant Death Syndrome (SIDS) family services provider; k. neonatologist; l. child advocate; m. chief juvenile probation officer; and n. child abuse prevention specialist.

2. If you want to convene an information meeting about CFRT in your community, contact the Texas CFRT

Committee Coordinator, Susan Rodriguez (susan.rodriguez@dshs.state.tx.us) to schedule a date to travel to your community to make a presentation, answer questions and facilitate discussion about team formation and child death review. The Coordinator will provide materials to share as you invite others to the meeting.

3. Invite representatives of all of the CFRT member disciplines to the convened meeting. 4. Host the convened meeting with the Texas CFRT Coordinator. After sharing information and discussing

how a team would benefit the safety of community children, the attendees and their respective agencies must commit to forming a team. The commitment to formation of a CFRT is formalized by:

a. a member agency volunteering to serve as Coordinator (who receives the death records from Texas Vital Statistics, schedules the meetings, informs the team members of which deaths they will be reviewing, and collects and submits the data on the online national child death review database);

b. election of a Presiding Officer (who facilitates the CFRT meetings and serves as the voice of that team);

c. all members and their respective agencies sign an Interagency Agreement agreeing to share information about the child death in the team meetings; and

d. all members and their respective agencies agree to honor confidentiality and sign a Confidentiality Statement.

5. Once steps 4a – 4d are completed, the Texas CFRT Coordinator is notified and the team is formally

recognized by DSHS. Texas Vital Statistics will begin supplying death certificates to the team for review. 6. The new team begins reviewing child deaths. Teams must meet at least once a year. Depending

upon the number of child deaths, teams typically meet quarterly, every other month or monthly.

7. The team Coordinator and/or other team member are set up to have access to the National Child Death Review Database so the data collected in the reviews can be entered in the secure online system.

Appendix D - 1

Appendix E: Population by Age

Race/Ethnicity, & Gender, Texas 2005

Appendix E - 1

POPULATION BY RACE/ETHNICITY AND AGE, 2005

Source: State of Texas Demographer, http://txsdc.utsa.edu

547106, 22%

646846, 26%

696095, 28%

136252, 6%447437, 18%

41331, 5%

161105, 21%

205641, 26%

228323, 30%

140803, 18%

189498, 7%

692737, 25%

717586, 26%

740217, 27%

427758, 15%14286, 7%

53016, 24%

55384, 25%

60016, 27%

36740, 17%

White (n = 2,473,7362) Black (n = 777,203)

Hispanic (n = 2,767,796) Other (n = 219,442)

< 1 yr. 1 – 4 yrs. 5 – 9 yrs. 10 – 14 yrs. 15 – 17 yrs.

Appendix E - 2

POPULATION BY GENDER, 2005

Source: State of Texas Demographer, http://txsdc.utsa.edu

0

5

10

15

20

25

30

35

40

45

50

55

Male Female

%

3,187,486 3,050,691

Appendix F: Trends in Texas Child

Death by Age, Race/Ethnicity, &

Gender, 1990 – 2005

Appendix F - 1

Source: Texas DSHS, VSU, 1990-2005

TREND OF TEXAS CHILD DEATH BY AGE, 1990 THROUGH 2005 RATES PER 100,000 CHILDREN PER AGE GROUP

30

35

40

45

50

55

1990

1992

1994

1996

1998

2000

2002

2004

10

15

20

25

30

35

1990

1992

1994

1996

1998

2000

2002

2004

10

15

20

25

30

1990

1992

1994

1996

1998

2000

2002

2004

Ages 1 to 4 years Ages 5 to 9 years

Ages 10 to 14 years

Appendix F - 2

Source: Texas DSHS, VSU, 1990-2005

TREND OF TEXAS CHILD DEATH BY RACE/ETHNICITY, 1990 THROUGH 2005 RATES PER 100,000 CHILDREN PER RACIAL/ETHNIC GROUP

50

55

60

65

70

75

80

1990

1992

1994

1996

1998

2000

2002

2004

90100110120130140150160

1990

1992

1994

1996

1998

2000

2002

2004

60

65

70

75

80

85

90

1990

1992

1994

1996

1998

2000

2002

2004

White Black

Hispanic

30

40

50

60

70

1990

1992

1994

1996

1998

2000

2002

2004

Other

Appendix F - 3

Source: Texas DSHS, VSU, 1990-2005

TREND OF TEXAS CHILD DEATH BY GENDER, 1990 THROUGH 2005

RATES PER 100,000 CHILDREN PER GENDER GROUP

50

55

60

65

70

75

80

1990

1992

1994

1996

1998

2000

2002

2004

707580859095

100105110

1990

1992

1994

1996

1998

2000

2002

2004

Female Male